U P DAT E Quarterly Update: What Body Parts and Procedures Are Associated with Wrong-Site Surgery? John R. Clarke, MD The six wrong-site procedures in Pennsylvania operating suites this quarter were an Editor, Pennsylvania Patient Safety Advisory all-time low since reporting of patient safety events began in mid-2004 (see Figure). Two Clinical Director, Pennsylvania Patient Safety Authority Professor of Surgery, Drexel University of the procedures were wrong-side anesthesia blocks. Two were wrong-side pain blocks. One was a wrong-side needle localization of a breast lesion for a breast biopsy. One was the removal of a wrong skin lesion. Going into 2013, 88 days passed since a surgeon had operated on the wrong site in the operating room (OR) and 20 days passed since an anesthesiologist had blocked the wrong site. Some near-miss reports from this quarter illustrate the importance of using the time- out as a final check for information errors: The CRNA [certified registered nurse anesthetist] gave the report to the circulator stating consents were signed and the patient was marked. The patient stated right ear surgery when asked upon entering the OR, and the right ear was marked. The his- tory and physical noted right ear surgery. When reading the OR consent [during the] time-out, the RN [registered nurse] noticed no right or left ear was noted in the surgery description. The time-out stopped until [the ear was] clarified. The surgeon agreed it was the right ear. The patient was on the OR schedule for a left inguinal hernia. The circulating nurse opened the electronic patient record in preparation for the procedure and used the information for this patient to complete the information on the time-out board. The cir- culating nurse retrieved the patient from the preoperative area, confirming the patient’s identity with the parents, the chart, and the patient bracelet. The circulating nurse entered the OR with the patient and proceeded to perform a time-out, identifying the patient, birth date, weight, allergies, and procedure. During the time-out procedure, the nurse anesthetist asked why the patient’s first name on the time-out board was different from the patient bracelet and patient chart. The surgeon stated the patient was a twin and the twin had been scheduled instead incorrectly. Another report illustrates the struggle facilities have ensuring compliance with best practices to prevent wrong-site surgery with the time-out: The doctor inserted the cystoscope prior to the time-out. When reminded, he continued the procedure while doing the time-out. [He was] reminded again of the need to wait to start the procedure until after the time-out, and the doctor continued talking. Recently, Mehtsun et al.1 reviewed surgical “never events” in the National Practitioners Data Bank from September 1, 1990, through September 30, 2010. For wrong-site, wrong-procedure, and wrong-patient events, they identified an average payment of $179,575, in 2010 US dollars, for each of an average of 250 events with payments per year. They extrapolated a total of 2,058 wrong-site, wrong-procedure, or wrong-patient occurrences per year in the United States. When outcomes were described for events resulting in payments, 8% resulted in deaths, 48% in permanent injury, 42% in tem- porary injury, and 2% in emotional injury. Scan this code AN ANALYSIS OF 500 WRONG-SITE SURGERIES with your mobile The first 500 wrong-site surgery events reported to the Pennsylvania Patient Safety device’s QR Authority between July 2004 and August 2012 were reviewed for the relationship reader to access between the type of wrong-site event, the procedure intended, and the location of the the Authority's intended incision. The primary intent was to answer the question: What sites benefit wrong-site surgery prevention toolkit. from marking and having the mark referenced during the time-out? Page 34 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority Figure. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year NUMBER OF REPORTS 80 70 Apr to Jun 21 19 60 Jan to Mar 8 16 11 9 Oct to Dec 50 14 17 21 16 10 11 Jul to Sep 40 16 14 19 11 30 13 15 17 17 16 13 11 20 15 6 10 23 23 16 19 17 16 16 12 11 MS13066 0 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 ACADEMIC YEAR Wrong-Patient Events Two reports documented suboptimal patient’s statements of two identifiers. Of the 500 events, 9 (1.8%) were OR patient identification practices: This “active voice” verification of the procedures done on the wrong patient, The physician entered and identified patient’s identity has been observed dur- approximately 1 per year. However, the patient by first and last name. ing site visits at multiple facilities involved 32 months passed since the last report The patient responded affirmatively. in collaborations to prevent wrong-site of an OR procedure on the wrong patient . . . The RN entered and identified surgery. in Pennsylvania. the patient by name, and the patient Of the 9, 8 involved the use of incorrect responded affirmatively. . . . The RN Wrong-Procedure Events information, as follows: spelled the patient’s last name, and Physicians initiated a wrong procedure the patient responded affirmatively. during 58 of the 500 events (11.6%), with — 4 involved patients with the same or 42 of the 58 wrong procedures (72.4%) similar names The patients were coming back to being completed. The types of procedures — 2 involved another patient’s informa- the OR out of order. . . . His name were as follows: tion entered in the chart bracelet was not checked, and he was not asked to identify himself. — 14 hand procedures — 1 involved using another patient’s However, the rarity of wrong-patient — 12 insertions of an incorrect device, chart events in the OR is consistent with good including 1 incorrect type of ear — 1 involved operating on patients out tubes of the scheduled order compliance with verification using the Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 35 ©2013 Pennsylvania Patient Safety Authority U P DAT E — 10 ear, nose, and throat (ENT) proce- inside the mouth, she saw the surgeon Wrong-Location Events dures, including the previously noted was removing the right tonsil. [The Physicians initiated an intended proce- event involving ear tubes scrub nurse and surgeon] both noted dure at an incorrect site on the correct — 5 eye procedures at that time the patient was for patient according to 433 of the 500 event — 4 gynecological procedures adenoidectomy. reports (86.6%). The errors in the loca- — 3 breast procedures The patient was scheduled for a right tion of the incisions or punctures were trigger thumb release. The surgeon subdivided as follows: — 3 orthopedic procedures made the incision for carpal tunnel — 1 procedure started on the wrong — 3 urological procedures release. The surgical tech questioned side and at the wrong spinal level — 2 pain management procedures the procedure. (counted as half for each). — Plus a bariatric procedure, a hernia The patient was scheduled for left — 306 other procedures started on the repair, and a wrong endoscopy trigger thumb release. . . . The patient wrong side. The wrong-hand procedures exhibited held up her marked thumb, which — 64 other procedures started at the an interesting pattern: 12 of the 14 were was initialed by [the doctor]. . . . The wrong level of the spine (63) or rib incisions for unintended carpal tunnel patient was prepped and draped. The cage (1). release. For 9 of the 12, the intended time-out was announced-—the patient procedure was a trigger finger release, not — 59 procedures started at a wrong name and proper procedure [were location near the correct location. a carpal tunnel release, exactly the same verified]. [The doctor] began inject- situation described in a case report in the In three reports, the information ing the palm as though he was doing New England Journal of Medicine.2 was insufficient to make such a a carpal tunnel instead of a trigger determination. Of the 58 wrong procedures, 9 were thumb release. The CRNA asked [the additional procedures to those that were doctor] if he was injecting for a car- pal tunnel instead of a trigger thumb. Wrong-Side Events intended. Of those, 3 were unintended tonsillectomies in addition to planned [The doctor] stopped. Counting the report of a procedure adenoidectomies, 2 were unintended started both on the wrong side and at Some of the unintended carpal tunnel bilateral salpingo-oophorectomies in addi- the wrong level, 307 OR procedures releases were facilitated by the absence of tion to planned hysterectomies, and 1 were initiated on the wrong side of body. a site mark or time-out: was a bilateral myringotomy instead of a Wrong-side procedures constituted the unilateral myringotomy. Scheduled for release of trigger finger; vast majority (61.3%) of all 500 wrong-site consent indicated same; site marked surgery reports. They represented 71.3% The tendency to do carpal tunnel releases by surgeon; . . . during prep, site of all intended procedures done on the instead of trigger finger releases, tonsil- mark washed off with alcohol; MD correct patient but initiated at the wrong lectomies with adenoidectomies, and proceeded to do carpal tunnel, then location on the body among the 430 salpingo-oophorectomies with hysterec- realized he was to do trigger finger; . . . patients for whom the location could tomies suggests problems of automatic MD told staff he was thinking about be determined. thinking by the surgeons and the need for a patient he had done previous day; OR staff to maintain situational aware- The exact anatomic location of the sur- MD said the time-out was done. ness of the intended procedures through- gery was described for 283 of the 307 out all operations: Time-out was not performed. Incision wrong-side procedures and is presented made for left carpal tunnel. Surgeon in Table 1. For some of the events, the The patient was in the OR for realized patient was to have release of wrong-side error did not occur during the bilateral myringotomy with insertion trigger finger. primary procedure but during the anes- of PE [pressure equalization] tubes thesia block or the tissue donor site proce- and adenoidectomy. The patient was Patient was scheduled for a trigger finger release. . . . No time-out process dure. Wrong-side anesthesia blocks done draped, and a time-out was performed by anesthesiologists accounted for 104 of prior to beginning the myringotomy. was completed. The surgeon started the procedure and made an incision the 307 wrong-side procedures in the OR When the bilateral myringotomy was (33.8%), and wrong-side pain procedures completed, the surgeon placed the as if the patient were undergoing a carpel tunnel release. The surgeon accounted for another 41 (13.4%). Surgi- mouth gag. The scrub nurse set up cal procedures accounted for slightly more the coblator, and, when she looked immediately realized his error. than half (52.6%). Page 36 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority Table 1. Areas with Wrong-Side Operating Room Procedures Of the 43 wrong-side spinal procedures, 29 (67.4%) were injections to control pain. NO. OF WRONG-SIDE ANATOMIC LOCATION PROCEDURES The need for intraoperative verification of Knees 52 ureteral stent placement with imaging stud- ies has been discussed in a previous issue of Spine 43 the Pennsylvania Patient Safety Advisory.3 Eyes 33 The only wrong-site emergency trauma Legs 26 procedures done in the OR were wrong- Ureters 25 side craniotomies, as illustrated by the following: Feet 16 Shoulders 10 There was no consent obtained for this emergent case. The patient Neck 8 arrived intubated in the OR. The Ankles 7 OR staff was set up for a right Chest or lungs 7 craniotomy, but the surgeon was positioning the patient for a left Skull (craniotomies)* 7 craniotomy. The OR staff assumed Colon 6 amongst the rush of the case that Hips† 6 the case was booked wrong and that Inguinal hernias 6 it was a left-side craniotomy. [After making the incision, the surgeon] Breasts 5 recognized the operation was on the Ears 4 wrong side. The procedure was imme- Jaw 2 diately stopped. The dura was not opened. The incision was closed and Kidneys 2 dressed, and the patient was reposi- Nose 2 tioned for a right craniotomy. . . . No Ovaries 2 time-out [had been] done. Sinuses 2 A fracture by itself is not always adequate Testes 2 to indicate the correct site for surgery, as illustrated by the following: Abdominal wall 1 Buttocks 1 Surgery was scheduled and consent obtained for repair of a right hip Device implantations 1 fracture. The patient marked the Forehead (temples) 1 site, and team verification “pause” Hands 1 occurred. However, the patient was positioned with the left hip Parathyroid glands 1 draped and prepped, and the surgery Thyroid gland 1 proceeded. After the incision, the Tongue 1 error was realized. The incision was Vocal cords 1 sutured and the patient repositioned, and surgery resumed on the right hip. Vulva 1 Total 283 Wrong-Level Events * 5 of 7 craniotomies were emergencies for brain injuries Counting the report of the procedure † 1 of 6 hip procedures was for a hip fracture started both on the wrong side and at the wrong level, 65 OR procedures were initi- ated on the level of a multitiered skeletal Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 37 ©2013 Pennsylvania Patient Safety Authority U P DAT E structure. Wrong-level procedures consti- vertebral bodies used to verify the location upper thoracic spine procedures, there tuted 12.9% of all 500 wrong-site surgery of the procedure were mentioned in 53 was a tendency to erroneously identify reports. They represented 15.0% of all reports. Most of the vertebrae intended to vertebrae that were more caudad (closer intended procedures done on the correct be used for intraoperative verification of to the coccyx). For lower thoracic and patient but initiated at the wrong location the spinal procedure were in the lumbosa- lumbosacral spine procedures, there was a on the body among the 430 patients for cral region of the spine (55.7%), followed tendency to erroneously identify vertebrae whom the location could be determined. by the cervical region (30.2%) and the that were more cephalad (closer to the All but one of the wrong-level events was a thoracic region (14.2%). For cervical and head) (see Table 2). procedure done at the wrong spinal level. One event of the 500 was the resection of Table 2. Errors in Verification of Vertebral Bodies the second rib, instead of the first rib, on the correct side. For events requiring intra- ERRORS ERRORS VERT.* NO.† CAUDAD‡ CEPHALAD§ TENDENCY operative verification of the correct level of a skeletal structure by imaging studies, C1 0 the event is not considered a wrong-level C2 0 event if a correct adjustment is made in C3 5 4 1 Caudad the location in response to the intraopera- tive verification before the definitive part C4 6 5 1 Caudad of the procedure is initiated. C5 9 6 3 Caudad Of the 64 wrong-level spinal procedures, C6 8 4 4 Even one event described a patient who had C7 4 2 2 Even a lumbar procedure instead of a cervical procedure: T1 0 T2 0 The patient was scheduled for an epidural steroid injection. . . . The T3 0 time-out was done using the consent. T4 0 However, the site had not been marked in the preoperative area and the con- T5 1 1 0 Caudad sent did not specify a site. The patient T6 1 1 0 Caudad stated only that he was having an T7 2 1 1 Even epidural steroid injection. The doctor T8 2 0 2 Cephalad stated during the time-out that the lumbar area was the correct area. After T9 2 0 2 Cephalad the lumbar procedure, the CRNA T10 2 0 2 Cephalad discovered “cervical” on the medical T11 3 0 3 Cephalad record and informed the physician. T12 2 1 1 Even Of the 64 reports of wrong-level spinal L1 2 0 2 Cephalad procedures, 57 (89.1%) were open pro- cedures and 7 (10.9%) were pain proce- L2 7 3 4 Cephalad dures. Open spinal procedures were more L3 9 3 6 Cephalad likely to be done at the wrong level (56) L4 19 7 12 Cephalad than on the wrong side (13), not consider- ing the procedure done at both the wrong L5 18 7 11 Cephalad level and on the wrong side. S1 4 1 3 Cephalad Of the 64, 6 might have been due to pre- S2 0 operative information errors and 56 were * Vert. = Intended vertebral body most likely due to intraoperative misper- † No. = Number of misidentifications involving the intended vertebral body ceptions; the sources of error were ambig- ‡ Errors Caudad = Wrong level is closer to the coccyx uous for 2. The intended and erroneous § Errors Cephalad = Wrong level is closer to the head Page 38 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority The importance of specifying the The value of the NASS suggestion of an — 3 vascular access procedures that exact location of a spinal procedure additional reading of the verification started at other than the intended on documents used for verification is image by a radiologist, as well as the location illustrated by the following report: surgeon,4 is illustrated by another report: — 2 device implantations that started at The patient was brought into The patient has a transitional lum- other than the intended location OR. . . . Left side was verified bar vertebra. The surgeon performed Unique events among the 500 reports with the physician. The physician surgery at the L3-4. The patient involved the wrong tooth, the wrong announced Left 4. Surgical consent remained symptomatic. Review of cardiac vessel, the wrong part of the cor- stated lumbar epidural injection the films with the radiologist deter- rect lung, the wrong midline hernia, the with no level or side specified. Left mined that the radiologist and the wrong part of the perineum, the wrong 4 lumbar epidural injection was surgeon were counting differently (one end of the femur, the wrong side of the completed. The physician returned included the transition vertebra and internal knee, the wrong muscle, and an in the afternoon to perform other one did not), resulting in confusion of incorrectly placed incision over the lower procedures and realized he had an the level for surgery. The patient was spine. One event was described only as incorrect schedule from his office, taken back to the OR, and surgery at medial instead of lateral. which led to the realization that L2-3 [was done] with good results. These events illustrate the importance of he had done the wrong level on the Reasons for misreading the landmark the following: morning patient. vertebra included transitional vertebrae, — Locations of procedures should be The value of following the North lumbarization of the sacrum, prior documented as specifically as pos- American Spine Society (NASS) fusions, osteoporosis, kyphosis, and obe- sible (e.g., medial or lateral, proximal suggestion of using an intraoperative sity, among many other pathologies that or distal). imaging study—after surgical exposure of could lead to confusion. — Marks referencing the location of the the operative site, using markers that do surgery on hands, fingers, feet, and not move—to confirm the vertebral level Other Wrong-Location Events toes should be placed as close as pos- to be operated4 upon is illustrated by the There were 59 intended procedures done sible to the intended incision site. following report: on the correct patient but initiated at the — The exact location of skin and subcu- Spinal procedure completed at wrong location other than the wrong side taneous lesions should be marked. unintended level. Discectomy was or wrong level. They constituted 11.8% of all 500 wrong-site surgery reports and rep- Localizing breast lesions is more complex planned for L2-3 but performed resented 13.7% of all intended procedures and may be discussed in a future issue of at L3-4. This error was detected done on the correct patient but initiated the Advisory. intraoperatively, and the surgery was extended to include the intended at wrong location on the body among the procedure. . . . Surgical site verification 430 patients for whom the location could SUMMARY was performed according to our policy be determined. Analysis of 500 consecutive wrong-site and did not include intraoperative These procedures were initiated at loca- surgery reports identified the following imaging to confirm the level. tions near the correct locations: themes: The importance of using stable markers to — 14 procedures that started on the — The process of having the patient verify, rather than estimate, the intended wrong part of the correct hand or state two identifiers to verify their vertebra is illustrated by this report: fingers identity appears to be effective in An intraoperative fluoroscopy was preventing wrong-patient errors. — 11 procedures involving the removal used to localize the incision over of the wrong skin or subcutaneous — Preoperative documentation of the C5-6. Fluoroscopy revealed that lesion site of surgery should be specific needle was at C4-5, so dissection was enough for all OR team members — 9 procedures that started on the carried further distally to the pre- to anticipate the correct location of wrong part of the correct breast sumed C5-6 level. The procedure was the mark. — 7 procedures that started on the completed. However, a follow-up x-ray — Marks should be made as close to the wrong part of the correct foot or toes revealed that the site was C6-7. intended incisions as possible. The — 3 procedures that started on the wrong side of the correct elbow Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 39 ©2013 Pennsylvania Patient Safety Authority U P DAT E exact location of skin and subcutane- of all wrong-side errors and 21% of — Wrong-level spinal procedures ous lesions should be marked. all wrong-site errors in the OR area. represent 13% of all wrong-site — The most likely wrong-site error, by — Some wrong procedures may result procedures. Intraoperative misper- far, is a wrong-side error. Bilateral from surgeons becoming distracted ceptions were reported nine times as structures, especially extremities during the operation. The OR team often as errors based on misunder- and eyes, are most likely to experi- should maintain situational aware- standings of information available ence wrong-side surgery. The most ness of the intended procedures preoperatively. The prevention common wrong-side error is the throughout the case, not just at the of wrong-level spinal procedures anesthetic block, accounting for 34% start of the case. requires intraoperative verification of the correct spinal level. NOTES 1. Mehtsun WT, Ibrahim AM, Diener- Hospital: case 34-2010: a 65-year-old ADVISORIES/AdvisoryLibrary/2010/ West M, et al. Surgical never events woman with an incorrect operation Mar7(1)/Pages/26.aspx. in the United States [online]. Surgery on the left hand. N Engl J Med 2010 4. North American Spine Society. Sign, 2012 Dec 17 [cited 2013 Jan 29; Nov;363(20):1950-7. mark & x-ray (SMaX): a checklist epub ahead of print]. http://www. 3. Quarterly update on the preventing for safety [online]. 2001 [cited 2013 sciencedirect.com/science/article/pii/ wrong-site surgery project: digging Jan 29]. http://www.spine.org/ S003960601200623X. deeper. Pa Patient Saf Advis [online] Documents/SMaXchecklist.pdf. 2. Ring DC, Herndon JH, Meyer GS. Case 2010 Mar [cited 2013 Jan 29]. http:// records of the Massachusetts General www.patientsafetyauthority.org/ Page 40 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 1—March 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 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. 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