U P DAT E Update on Wrong-Site Surgery: Reports from Ambulatory Surgical Facilities Theresa V. Arnold, DPM From July 2004 through September 2016, 717 wrong-site operating room (OR) surgery Manager, Clinical Analysis events, including wrong-site anesthesia events, were reported through the Pennsylvania Pennsylvania Patient Safety Authority Patient Safety Reporting System (PA-PSRS) and analyzed by the Pennsylvania Patient Safety Authority. Analysis of wrong-site surgery events reported to the Authority by ambulatory surgical facilities (ASFs) identified an increase in these reported events over time. The average incidence of wrong-site surgery* in Pennsylvania ORs continues to be about one event each week.1 Analysis of events reveals that ASFs reported about 29% of all wrong-site surgery events between July 2004 through June 2016 (i.e., 203 of 702); an average of one event every three weeks. Figure 1 demonstrates an increase in the percentage of wrong-site events reported from ASFs over the 12-year period. The rising trend is appar- ent in the most recent seven academic years (i.e., July 2009–2010 year through June 2015–2016) for which the percentage of events increased from 29% to 34.2% (i.e., 129 of 377). Based on the analysis of wrong-site events reported by ASFs in the most recent seven academic years (N = 129), the most commonly reported events and procedures are noted in Figure 2 and included the following: —— Wrong side (60.5%, n = 78): blocks (by anesthesiologists and surgeons), pain man- agement procedures, and eye procedures —— Wrong site (31.8%, n = 41): excisions and biopsies, pain injections, hand proce- dures (e.g., incision placement) —— Wrong procedures (7.8%, n = 10): tonsillectomy (e.g., instead of or in addition to adenoidectomy when only adenoidectomy was intended) and hand procedures * For this analysis, the average number of wrong-site surgery events reported weekly over 12 academic years (i.e., July 2004 through June 2016) was calculated as follows: 702 events ÷ (12 × 52 weeks/year). Figure 1. Percentage of Wrong-Site Surgery Events Reported by Ambulatory Surgical Facilities by Academic Year PERCENTAGE 100 90 80 70 60 50 37 38 37 35 40 32 32 25 26 24 27 25 30 20 MS16900 10 17 0 Scan this code 3 14 15 16 07 08 9 10 1 2 05 06 01 01 01 00 with your mobile 20 20 20 20 20 20 20 20 o2 o2 o2 o2 device’s QR reader to to to to to to to to t t t t to access the 13 14 15 11 12 04 05 06 07 08 09 10 20 20 20 20 20 20 20 20 20 20 20 20 Authority's toolkit on this topic. ACADEMIC YEAR Page 160 Pennsylvania Patient Safety Advisory Vol. 13, No. 4—December 2016 ©2016 Pennsylvania Patient Safety Authority (e.g., carpal tunnel surgery instead of Figure 2. Type of Wrong Surgery Events Reported by Ambulatory Surgical Facilities trigger finger release) from July 2009 through June 2016 —— Although ASFs and hospitals reported similar types of “wrong” events, there were two notable dif- 8% ferences in the events reported from hospitals, which reported: (1) wrong- level spinal procedures were the Wrong side most commonly reported wrong-site 32% procedure, and (2) the wrong patient Wrong site received an unintended procedure in about 2% of reported events. 60% Wrong procedure UPDATE ON WRONG-SITE SURGERY MS16901 From July 2004 through September 2016, 717 wrong-site operating room (OR) surgery events, including wrong-site anes- thesia events, were reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) and analyzed by the Pennsylvania Patient Safety Authority. The three most common types of wrong-site Figure 3. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year procedures reported through PA-PSRS since July 2004 have remained consistent and account for about 50% of all wrong- NUMBER site surgery events: OF REPORTS Jul to Sep Oct to Dec Jan to Mar Apr to Jun 80 1. Perioperative anesthesia blocks administered by anesthesiologists 21 and surgeons (25.9%, n = 186 60 19 8 16 of 717) 11 14 9 21 2. Spinal procedures (e.g., wrong level; 17 21 16 10 40 11 16 10 13.0%, n = 93) 19 18 16 10 14 3. Pain-management procedures 15 11 15 17 13 12 (11.4%, n = 82) 17 17 13 10 20 13 11 15 The percentage of wrong-site anesthesia 23 23 6 11 15 19 17 21 MS16899 blocks marginally decreased from the 16 16 16 13 15 11 10 9 last update2 in June 2016 (i.e., 26.4%* 0 to 25.9%). However, a broader analysis 20 -05 20 -06 20 -07 20 -08 20 -09 20 -10 20 -11 20 -12 20 -13 20 -14 20 -15 20 -16 7 -1 reveals a 6.5% improvement in the per- 04 05 06 07 08 09 10 11 12 13 14 15 16 centage of wrong-site blocks reported over 20 the last eight quarters (i.e., from 27.7% in the second quarter of 2014–2015 to ACADEMIC YEAR * The percentage of wrong-site anesthesia blocks reported in the June 2016 update (i.e., 26.6%) differs from percentage noted above (i.e., 26.4%) because three additional wrong-site surgery events were reported to the Authority through March 2016 (i.e., 692 instead of 689). Vol. 13, No. 4—December 2016 Pennsylvania Patient Safety Advisory Page 161 ©2016 Pennsylvania Patient Safety Authority U P DAT E 25.9% through the first quarter of 2016– was administered by an anesthesiologist SUMMARY 2017). Further analysis of these events on the wrong side of the body and two The data trends outlined in this update in the last eight quarters revealed that by hand surgeons at the wrong site of the demonstrate the most common types 40% of wrong-site anesthesia blocks were correct hand. Similarly, pain management of wrong-site events reported from administered by anesthesiologists and procedures (the majority of which were Pennsylvania facilities that provide 60% by surgeons. During this two-year wrong-side spinal injections) accounted surgical services. Sharing this, and time period, the surgeons most com- for 12% (n = 3) of the reported events. data collected internally, with surgical monly involved in wrong-site blocks were Additional wrong-site surgery events staff and surgeons may help to identify hand specialists, ophthalmologists, and reported in the most recent two quarters potential areas for process improve- orthopedists. were as follows: ment. Please reference the Authority’s The percentage of wrong-site surgeries “Preventing Wrong-Site Surgery” toolkit —— Wrong-side procedures (20%, n = 5 related to wrong-level spinal procedures at http://patientsafetyauthority.org/ of 25); including one ureteroscopy/ and wrong-site pain-management proce- EducationalTools/PatientSafetyTools/ ureteral stent placement dures were essentially unchanged from the PWSS/Pages/home.aspx for patient safety —— Wrong-site procedures (16%, n = 4); tools (e.g., Self-Assessment Checklists, June update. Since July 2004, the majority including two wrong-site biopsies Observational Monitoring Tools, of wrong-level spinal procedures were per- formed at the lumbar level (53%, n = 49 —— Wrong procedures (16%, n = 4); Principles for Reliable Performance of of 93), followed by the cervical level (27%, including one ophthalmology pro- Correct-Site Surgery) developed to assist n = 25), and thoracic level (16%, n = 15). cedure (i.e., incorrect strabismus facilities prevent wrong-site surgery and The spinal level was not specified in 4% procedure) patient harm. The Authority also has a (n = 4) of the reported events. —— Wrong patient (4%, n = 1); a wrong consultation program for Pennsylvania (intended for another patient) gyne- facilities that wish to evaluate their oppor- Twenty-five wrong-site surgery events were cologic procedure tunities to improve wrong-site surgery reported from Pennsylvania facilities since Please note: one wrong-site event was prevention processes, particularly follow- the last published analysis in June. One of belatedly reported or recognized in each ing a wrong-site event or near miss in a the most common types of event reported of the following academic quarters: the surgical suite. Those interested in this was a spinal procedure performed at second quarter of 2009–2010; the first program should contact the Authority the wrong level, which accounted for quarter of 2014–2015; and the third office or their regional patient safety liai- 20% (n = 5 of 25); three were performed quarter of 2015–2016. Adjustments in the son (PSL). The Authority’s PSLs can help at the incorrect lumbar level and two number of reported events are reflected facilities assess their policies and proce- procedures were performed at the incor- in Figure 3. dures and arrange for onsite observations rect cervical level. Anesthesia blocks to evaluate surgical team compliance using accounted for 12% (n = 3), one of which the resources developed by the Authority. NOTES 1. Quarterly update on the Preventing 2. Arnold TV. Update on wrong-site Wrong-site Surgery Project. Pa Patient surgery: use patient engagement to Saf Advis 2010 Sep: http://patient- enhance the effectiveness of the univer- safetyauthority.org/ADVISORIES/ sal protocol. Pa Patient Saf Advis 2016 AdvisoryLibrary/2010/Sep7(3)/ Jun;13(2):77-8. Also available: http:// Pages/108.aspx. patientsafetyauthority.org/ADVISO- RIES/AdvisoryLibrary/2016/jun;13(2)/ Pages/77.aspx. Page 162 Pennsylvania Patient Safety Advisory Vol. 13, No. 4—December 2016 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 4—December 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. 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