U P DAT E Quarterly Update on Wrong-Site Surgery: Areas to Focus Attention John R. Clarke, MD Ten wrong-site procedures were reported in Pennsylvania operating suites this past Editor Emeritus, Pennsylvania Patient Safety Advisory quarter, the lowest yet recorded for the first quarter of any academic year since report- Clinical Director, Pennsylvania Patient Safety Authority ing began. Another two were reported belatedly for last quarter, raising the total for the Professor of Surgery, Drexel University last academic year to 48, which still represents the lowest total for any academic year. See Figure 1. In particular, problems with wrong-site anesthetic blocks, wrong-side pain procedures, and wrong-level spinal surgery persist, representing 4 of the 10 reported wrong-site pro- cedures. As yet another example of a wrong-side block, see the following: Physician at bedside . . . for pre-op femoral nerve block catheter placement on right side. During pre-op block time-out, physician verified right side. Physician proceeded with catheter placement without nurse in attendance. Nurse returned to bedside and . . . realized that the procedure was being done on the left side. Nurse immediately notified physician of the incorrect side. Procedure stopped, catheter removed. . . . Time-out redone for right femoral nerve block catheter, and correct procedure was done. NEAR-MISS REPORTS The following near-miss reports from this quarter illustrate both areas of continued weakness and the effectiveness of the evidence-based best practices to prevent wrong- site surgery.1,2 Problems with scheduling: Two scheduling cards stapled together. One stated a pre-op diagnosis of AAA [abdomi- nal aortic aneurysm] and the procedure being AAA repair. Other scheduling card has a pre-op diagnosis of right popliteal aneurysm with the procedure being ligation right popliteal aneurysm and right fem-pop bypass. . . . Computer also said pre-op diagnosis of AAA. This is the incorrect procedure according to the patient and the surgeon. Fixed early: Upon review of the printed schedule and discussion with the patient, it was determined that the surgery was entered in by the scheduler under the wrong extremity. This was caught early, and the surgery was performed on the correct foot. Problems with registration and patient identification: Patient presented to registration [for surgery]. However, the patient’s twin sister [had been] registered. Patient was banded with sister’s information [while confirming] her name and date of birth. . . . When registration went back to verify her information, the patient stated that it was her sister’s information that was registered. Patient was registered under wrong patient [name]. Incorrect DOB [date of birth] was entered and ID [identification] bracelet and stickers were printed for this wrong patient. When registration person . . . went to get info from the patient, he discovered that this was the wrong information for this patient. Preoperative verification and marking continue to be done ineffectively or not at all: Scan this code Patient arrived in OR [operating room]. Operative consent stated incision and drainage with your mobile of right middle finger. Patient’s right index finger marked for surgery, and abscess pres- device’s QR reader ent on the index finger. Patient stated procedure to be done on the index finger. Consent to access the changed by the surgeon in the OR to “Incision and drainage of right index finger.” Authority's toolkit on this topic. Upon reviewing the consent during the time-out, it was noticed that the . . . consent did not specify the area of the spine that was to be exposed. The consent should have read “exposure of the lumbosacral spine” but instead read “exposure of the spine.” Page 142 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority Figure 1. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year NUMBER OF REPORTS Apr to Jun 80 Jan to Mar 70 21 Oct to Dec 19 60 8 16 Jul to Sep 11 9 50 14 17 21 16 10 11 40 16 19 18 14 11 30 13 15 17 17 16 13 13 11 15 20 6 10 23 23 16 19 17 16 16 13 MS13600 11 10 0 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 ACADEMIC YEAR Note from the preceding examples that the first). Notified charge nurse. An example of the patient providing discrepancies on the consents are to be Surgeon arrived and marked [second incorrect information: identified during the preoperative verifica- site] with X. Patient surgical site verified in hold- tion process prior to the patient entering Note that the use of an X to mark the site, ing area. Patient verified right total the OR. as indicated in the preceding example, hip. When brought to OR, patient Called [surgeon] to notify him of situ- is discouraged because it has ambiguous stated he was to have right shoulder ation. Surgeon [came] in five minutes meanings, such as “yes, the surgery is done. Family called to verify correct later and performed time-out for here” and “no, the surgery is not here.” procedure. . . . [Right hip also] veri- wrong patient. Surgeon did not know fied by surgeon. A near miss caught by an OR team mem- which patient was in the room. ber speaking up: Note that the operating team not only Patient brought to OR without surgi- checked in reconciling the information Assisting surgeon found that attend- but also double-checked. cal site being marked and [with] no ing surgeon had marked the patient history or physical completed. but that the spinal levels [marked] There were a number of chart problems After patient anesthetized, . . . it was were not correct. Attending surgeon reported this quarter: noted that patient was not marked. checked the patient with the consent Patient was on OR table being Patient with [two lesions]. Patient’s and x-rays. Patient was correctly draped. Staff member called for a second surgical site not marked (only marked before the start of the case. time-out, but the patient’s chart and Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 143 ©2013 Pennsylvania Patient Safety Authority U P DAT E Figure 2. Trends in Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Procedure NUMBER 35 33 30 30 27 25 25 22 21 21 20 20 18 16 15 15 14 1212 12 12 10 10 10 10 9 9 8 8 8 7 77 7 7 7 6 5 5 5 55 5 5 5 5 4 4 4 4 4 4 4 4 44 3 3 3 3 3 3 MS13616 2 2 2 2 2 2 1 0 0 Anesthetic blocks Pain Spinal surgery— Eye Ureteral Hand Remaining by anesthesia management wrong level surgery stents surgery procedures providers WRONG-SITE PROCEDURES Each procedure cluster of bar values represents academic years, from left to right, spanning 2004-2005 through 2012-2013. consent had not been brought [to the during the in-room interview between And notably, a good catch during a time- OR] with the patient from the the patient and the circulator. out for an organ donation: holding area. The chart and consent Another near miss, again caught by an The OR team [was sent] an e-mail were brought to the OR, and the OR team member speaking up: with the UNOS [United Network time-out was completed. for Organ Sharing] number prior to Patient was in the OR for total left surgery. That number did not match Patient arrived in block room. . . . On knee. During the time-out, staff read his chart, I found information for two exactly when the organ time-out incorrect patient information. Other was done. [Situation identified and other patients. staff in the room noted this error and corrected.] Anesthesia brought the correct patient corrected it till all were in agreement, to the room with the chart for a dif- and the case was then performed . . . ferent patient. The error was found as planned. Page 144 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority Table. Most Common Wrong-Site Procedures in the Operating Suite by Type, July 1, 2004, MAJOR AREAS OF FOCUS through June 30, 2013 (N = 541) In a previous update, the most common PROCEDURE NO. % wrong-site procedures were identified.4 Anesthetic blocks by anesthesia providers 115 21 The six most common, each representing Spinal surgery—wrong level 66 12 5% or more of all wrong-site procedures, are listed again in the Table, adjusted for Pain management 59 11 the addition of the two new reports from Hand surgery 34 6 the second quarter of 2013. Eye surgery 33 6 These six wrong-site procedures were Ureteral stents 29 5 tracked by year and compared with the Remaining procedures 205 38 remaining wrong-site procedures (see Figure 2). Overall, wrong-site procedures Note: Percentages do not add up to 100 due to rounding. have trended down 3.4% per year in reference to the overall yearly average. As in the previous quarter, specimens Compared with the remaining 38% second specimen, labeled left cheek, were identified as having been of wrong-site procedures, which have the pathologist again said the sutures mislabeled: trended down an average of 8.5% per year did not match the specimen being in reference to their yearly average, only Specimen received in cytology with from the left side. After a discussion eye surgery has seen a similar downward incorrect side from patient labeled. with the RN, the surgeon came out to trend (9.5%). Ureteral stenting and hand Received labeled as “left” renal wash- the frozen section room to discuss the surgery have less downward trending ing, when it was from the “right.” issue with the pathologist. Upon the than the overall yearly average (3.1% and surgeon coming out, they discovered The pathologist was in the frozen 2.2%, respectively). Anesthesia blocks the specimens were placed into the section room performing frozen sec- have been relatively unchanged (trending wrong containers. The first specimen tions for the surgeon. Upon grossing down 0.4% per year), while spinal surgery originally labeled right cheek was the first specimen labeled right cheek, and pain management procedures have actually the specimen from the left the pathologist noticed the sutures trended toward more wrong-site proce- cheek [and vice versa]. marking the margins did not correlate dures (upward 3.0% and upward 3.8% with the [description of the] specimen As cited in a previous Pennsylvania Patient per year, respectively). on the right side. The RN [registered Safety Advisory article, Bixenstine et al. These yearly trends suggest that the focus nurse] who brought the specimen out reported a study in which 23.8% of surgi- should be directed toward improving said it was mislabeled and should cal specimens had their laterality labeled the three most common types of wrong- have been labeled left cheek. The incorrectly.3 site procedures: anesthesia blocks, pain frozen section was then completed. As management procedures, and wrong-level . . . the pathologist was grossing the spinal surgery. NOTES 1. Pennsylvania Patient Safety Authority. surgery. Pa Patient Saf Advis [online] specimen identification defects. Am J Med Principles for reliable performance of 2010 Dec [cited 2013 Oct 21]. http:// Qual 2013 Jul-Aug;28(4):308-14. correct-site surgery [online]. 2012 Dec patientsafetyauthority.org/ADVISORIES/ 4. Clarke JR, Arnold TV. Quarterly update [cited 2013 Oct 21]. http://patient- AdvisoryLibrary/2010/dec7(4)/Pages/ on wrong-site surgery: work to be done. safetyauthority.org/EducationalTools/ 151.aspx Pa Patient Saf Advis [online] 2013 Sep PatientSafetyTools/PWSS/Documents/ 3. Bixenstine PJ, Zarbo RJ, Holzmueller [cited 2013 Oct 21]. http://patientsafety principles.pdf CG, et al. Developing and pilot testing authority.org/ADVISORIES/Advisory 2. Quarterly update: the evidence base for practical measures of preanalytic surgical Library/2013/Sep;10(3)/Pages/110.aspx best practices for preventing wrong-site Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 145 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 4—December 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. 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