Pennsylvania Patient Safety Advisory Quarterly Update on the Preventing Wrong-Site Surgery Project The published PA-PSRS data on wrong-site surgery Figure. PA-PSRS Wrong-Site Surgery Reports events has been revised as a result of discovering by Quarter events that were neither classified as wrong-site events, even though they were, nor classified as hav- ing occurred in an operating room or ambulatory NUMBER OF REPORTS surgical facility, even though they did. These data 30 supersede all previous PA-PSRS data on wrong-site surgery events. A revised graph of the cumulative 25 number of reports of wrong-site surgery events has 24 been extended through the fourth quarter of 2007 20 20 20 and replaces the previously published graph on the 19 Pennsylvania Patient Safety Authority’s Web site.* A 15 16 17 15 15 15 graph of the number of reports by quarter, also based 13 13 13 on the revised data (see Figure), has been added. 10 11 12 Please note that the current definition of wrong-site surgery follows the National Quality Forum definition 5 and includes punctures of the skin for the injection of local or regional anesthesia preparatory to the 0 scheduled procedure.1 An improved search strategy Q3 Q4 2004 Q1 Q2 2005 Q3 Q4 Q1 Q2 2006 Q3 Q4 Q1 Q2 2007 Q3 Q4 will be used for all future searches for wrong-site sur- REPORTS BY QUARTER gery reports. Although there has been a slight drop in the number of reports of wrong-site surgery events, PA-PSRS clinical analysts are not impressed that there Note that other elements that appeared to be associ- has been an improvement in wrong-site surgery inci- ated with error trapping in the initial preliminary dence in Pennsylvania. assessment of detailed wrong-site surgery reports (see the December 2007 Advisory) are not currently Detailed wrong-site surgery reports are being submit- associated in this analysis of the expanded data set. ted by cooperating facilities in follow-up to reports of The inverse association with scheduling errors dis- near-miss and actual wrong-site events. By comparing appeared, as did direct associations with the use of the processes that were and were not significantly asso- checklists and the use of time outs after repositioning ciated with trapping the error before harm occurred, the patient. the clinical analysts can better understand which pro- In a separate inquiry, analysts examined the subse- cesses are associated with successfully catching these quent experiences of facilities that indicated in a 2007 rare events. As of February 25, 2008, the analysts have survey** that changes were initiated as a result of the received the results of 34 in-depth queries about near- June 2007 Advisory article “Doing the ‘Right’ Things miss events and 14 about actual wrong-site surgery to Correct Wrong-Site Surgery.” Of 180 facilities that events from 33 cooperating facilities. The compliance returned survey responses, 62 indicated that changes rate with requests for detailed information within were implemented as a result of this particular article. 30 days of the event has been more than 63%. Cur- During the six months before the article published, rently, six elements of a prevention program for this group of facilities had reported six wrong-site wrong-site surgery are more commonly present when surgery events, in contrast to two wrong-site surgery errors were trapped than when the errors advanced to reports among the 118 facilities that did not indicate wrong-site surgery (see Table). The most persistent ele- a change as a result of this article. During the six ment, having also been the most apparent in the first months after the article, the numbers were exactly quarterly review that published in the December 2007 the same: six more wrong-site surgery reports among Advisory,* is the response of the surgeon to concerns the facilities that had made a change and two more that were raised by others. Surgeons participating in wrong-site surgery reports among those that had not. preoperative verification and reconciliation processes However, no facility in either response group reported also support the concept that involvement of the sur- a wrong-site surgery error in 2007 both before and geons in any program to prevent wrong-site surgery after the article. The new reports that were submitted is crucial. after the article was published were all from different facilities than the reports preceding the article. The Health Care Improvement Foundation (HCIF) * The Pennsylvania Patient Safety Authority has posted an online Partnership for Patient Care is implementing a toolkit of articles, educational resources, and data snapshots per- taining to wrong-site surgery. This toolkit, “Preventing Wrong-Site Surgery,” is available at http://www.psa.state.pa.us/psa/cwp/view. ** This survey refers to the annual online user survey conducted asp?a=1293&q=448010. among Patient Safety Officers in Pennsylvania. Vol. 5, No. 1—March 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 31 Pennsylvania Patient Safety Advisory Table. Current Preliminary Associations between Elements of a Prevention Program for Wrong-Site Surgery and Success in Trapping Wrong-Site Errors before Harm Occurred WRONG-SITE SIGNIFICANCE ELEMENT NEAR MISSES SURGERIES (P LESS THAN) Identification involved wristband and chart 27/27 11/13 0.05 Mark visible during time out 23/25 7/11 0.05 Surgeon did a preoperative verification 24/25 9/13 0.05 Surgeon reconciled discrepancies in documents 19/20 5/9 0.01 Someone raised a concern 24/26 5/12 0.001 Surgeon responded to the concern raised 19/20 3/11 0.001 Wrong-site Surgery Prevention Program for surgical information can be obtained by contacting the facilities in the greater Philadelphia area. Part of the Authority (patientsafetyauthority@state.pa.us; please program is to correlate elements on the Pennsylvania address requests to John Clarke, MD, Clinical Direc- Patient Safety Authority’s “Self-Assessment Checklist tor, Pennsylvania Patient Safety Authority). for Program Elements Associated with Prevent- ing Wrong-Site Surgery” with reports of wrong-site PA-PSRS analysts will continue to track and analyze surgery events. A more user-friendly version of the all reports of wrong-site surgery events and near checklist is now available on the Pennsylvania Patient misses. In the meantime, hospitals and ambula- Safety Authority’s Web site in the toolkit “Preventing tory surgical facilities are encouraged to assess their Wrong-Site Surgery.”* By comparing facilities that program for preventing wrong-site surgery using the do and do not have each element on the checklist checklist on the Authority’s Web site. Please consider with existing reports of wrong-site surgery events, the sharing these assessments and the success or failure analysts may gain some insight into which suggested of any efforts to improve wrong site surgery programs. elements are actually associated with fewer events. Facilities outside Pennsylvania are also welcome to share this information. All Pennsylvania facilities that conduct surgical procedures have been invited to join this voluntary Note endeavor. The Authority also invites any other state 1. National Quality Forum. Serious reportable events in collecting wrong-site surgery events to use the same healthcare—2006 update. Washington DC: National checklist to replicate the study. Requests for further Quality Forum; 2007. Page 32 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 1—March 2008 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 1—March 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 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 https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the PA-PSRS program, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the PA-PSRS program or the Patient Safety Authority, see the Authority’s Web site at www.psa.state.pa.us. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a non-punitive approach and systems-based solutions.