U P DAT E Quarterly Update on Wrong-Site Surgery: Marking for Regional Anesthetic Blocks John R. Clarke, MD As of July 23, 2014, there were 14 reports of wrong-site surgery in Pennsylvania operating Editor Emeritus, Pennsylvania Patient Safety Advisory rooms (ORs) during the second quarter of 2014 and 1 belated report from a prior quarter Clinical Director, Pennsylvania Patient Safety Authority (see the Figure). Despite the increase in reports of wrong-site surgery this quarter over the Professor of Surgery, Drexel University previous three quarters, the total for the academic year 2013-2014 is the lowest to date: 45. Of the 14 reports, 3 involved hand procedures, 2 were wrong-level spine operations, 2 involved ovarian surgery, and 1 of the other 7 was a wrong-side anesthesia block, which remains the most common wrong-site event for the academic year (n = 7 of 45) and the decade (n = 122 of 586). Two of the three incorrect-hand procedures involved starting a carpal tunnel procedure instead of the intended trigger finger release. This one type of error now represents 28% of all wrong-site hand surgery events (n = 11 of 39) and 2% of all wrong-site surgery events reported from July 1, 2004, through June 30, 2014. Near-miss reports continue to demonstrate both areas of continued weakness and the effectiveness of the evidence-based best practices to prevent wrong-site surgery.1,2 Operations continue to be scheduled incorrectly, introducing errors into the verifica- tion process: Procedure was booked as I&D [incision and drainage] of bilateral groin abscesses. Cor- rect procedure was completed, which was I&D of bilateral axillary abscesses. Patient was scheduled for shoulder arthroscopy. Office schedule listed “left.” OR schedule said “left.” Patient to preoperative holding [area]; consent, H&P [history and physical], and patient stated “right,” which is the correct side. The right side was confirmed and prepped. Fortunately, those receiving patient information have been checking for discrepancies and identifying them as soon as discovered for reconciliation by the surgeon based on primary sources of information: Patient consented for a left craniotomy. Anesthesia noted that patient was scheduled for a right craniotomy. Neurosurgeon notified. OR schedule indicates left parietal craniotomy. Consent indicates right craniotomy. While patient was in the preoperative holding area, the surgeon was notified of the discrepancy. MRI [magnetic resonance imaging scan] was reviewed (verified right side as correct side). Surgeon, patient, and nurse verified right side as correct. Surgeons marking the site are not always confirming the site prior to marking with all the relevant information and with the patient, as is obvious from the following: Presented for hysterectomy. Eye surgeon initialed above right eye, but this is not an eye patient. Eye surgeon was made aware and initials removed. This patient had the correct procedure completed. During preoperative assessment, the patient confirmed right-sided surgery. The surgeon marked the right side of patient. However, the consent read “left.” The error was discov- ered during the time-out verification. This patient was [scheduled] for a bilateral ophthalmic keratopathy. The procedure was confirmed as bilateral and the surgeon marked the patient bilaterally. It was noted dur- ing the time-out that laterality was not designated on the consent. The procedure was Scan this code completed bilaterally. with your mobile device’s QR reader The value of the mark is evident from this report: to access the Left leg was initially prepped and then staff realized that the patient was marked on Authority's toolkit the right and that the consent was also for the right side. Right leg prepped and proce- on this topic. dure started without issue. Page 136 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority Figure. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by number of reports for procedures on the Academic Year shoulder. NUMBER Another contrast was an increase in OF REPORTS Jul to Sep Oct to Dec Jan to Mar Apr to Jun anesthetic blocks on the legs by anesthesi- 80 ologists, despite a decrease in the number of wrong-site anesthetic blocks overall. 21 A statistically significant improvement 60 19 8 16 was observed for eye blocks by ophthal- 14 11 9 16 mologists, although that might have been 17 21 10 40 11 16 due to the shift to topical anesthetics. 14 19 18 14 11 However, other eye procedures were also 17 13 15 17 16 10 trending toward improvement. 20 13 11 15 13 23 23 6 11 Other commonly reported wrong-site pro- 19 17 MS14424 16 16 16 13 cedures were, if anything, more common: 11 10 0 wrong-level spinal surgery, procedures for pain management, and ureteral stenting. 5 6 7 8 9 0 1 2 3 4 -0 -0 -0 -0 -0 -1 -1 -1 -1 -1 04 05 06 07 08 09 10 11 12 13 The results by area indicate that focus 20 20 20 20 20 20 20 20 20 20 should continue on wrong-side leg blocks ACADEMIC YEAR by anesthesiologists, wrong-site hand sur- gery (especially absentmindedly starting a carpal tunnel release instead of a trigger fin- Switching ORs and running two rooms nurse and asked his/her name, and it ger release), wrong-level spine procedures, caused confusion resulting in the wrong was discovered that they were expect- wrong-side pain management procedures, patients being brought to these ORs: ing a different patient. and wrong-side ureteral stenting. A CRNA brought a patient into the OR suite not realizing that the IMPROVEMENT BY AREA MARKING THE SITE OF THE surgeon/patient’s room [had been] Analysts compared reports of wrong-site ANESTHETIC REGIONAL BLOCK swapped with that of another. The surgery for the first three years of facil- MAY PREVENT WRONG-SITE outcome was that once the patient ity reporting through the Pennsylvania REGIONAL BLOCKS entered the room and was identified Patient Safety Reporting System, before Marking the site of the surgical incision as the wrong patient, the patient had intense scrutiny with the onset of the has proven to be a useful reference to to be wheeled out. Both patients were wrong-site surgery project in July 2007, the correct surgical site during the time- [scheduled for] laparoscopic cholecys- with reports for the most recent three out before surgery.3 The act of marking tectomies by two different surgeons. years. Overall, there were 24% fewer the surgical site after verification of the Despite what the monitor said, the reports in the most recent three years correct site with the documents and the rooms were swapped and the CRNA compared with the initial three-year base- patient in the preoperative holding area was not aware of the circumstance. line (see the Table). Comparing specific may refresh the surgeon’s short-term Surgeon began swinging between two procedures to the overall experience, a memory prior to the final time-out. operating rooms, and patients were statistically significant improvement was Pointing to the mark on the surgical site being moved to different rooms. There observed for thoracic procedures (5 to 0) in the prepped and draped surgical field was confusion on which patient and orthopedic procedures on the knee is a valuable surrogate for verbal confir- was going to which room, and the (11 to 2), with reductions of reports of mation by the patient, who is usually patient was sent to the surgeon’s wrong-site events for all surgical proce- anesthetized and unable to otherwise par- other operating room. The planned dures on the leg. ticipate in the final time-out process.3 procedure remained the same (right In contrast, there was minimal reduction Using the three steps of the Universal knee arthroscopy) and no equipment of reports of wrong-site events for proce- Protocol4 when doing a regional needed [to be] changed. However, the dures on the hand, none for procedures patient was greeted by the circulating on the elbow, and an increase in the (continued on page 139) Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 137 ©2014 Pennsylvania Patient Safety Authority U P DAT E Table. Reductions in Wrong-Site Operating Room Procedures by Type PROCEDURE TYPE 2004 TO 2007 2011 TO 2014 (MOST % DECREASE (BASELINE) RECENT PERIOD) All 187 142 24.1 Eye blocks by surgeons 8 0 100.0* Thoracic 5 0 100.0* Colon 4 0 100.0 Orthopedic ankle 2 0 100.0 Orthopedic knee 11 2 81.8* Wrong device inserted 7 2 71.4 Ear, nose, and throat 6 2 66.7 Eye surgery 13 5 61.5 Knee blocks by surgeons 6 3 50.0 Graft harvest 4 2 50.0 Craniotomy 2 1 50.0 Orthopedic femur and hip 2 1 50.0 Urological procedures except ureteral 2 1 50.0 Endocrine 2 1 50.0 Wrong-side spinal surgery 5 3 40.0 Foot 9 6 33.3 Eye blocks by anesthesiologists 3 2 33.3 All pre-op anesthesia blocks 48 34 29.2 All blocks by anesthesiologists 32 26 18.8 Hand 13 12 7.7 Vascular and dialysis 3 3 0.0 Elbow 1 1 0.0 Dental and oral surgery procedures 1 1 0.0 Wrong-level spinal surgery 19 23 Increased Pain management 19 21 Increased Ureter 9 10 Increased Leg blocks by anesthesiologists 6 9 Increased Breast 4 6 Increased Gynecological 2 4 Increased Wrong lesion 2 4 Increased Hernia 1 2 Increased Shoulder 0 2 Increased Bariatric 0 1 Increased Note: Events total more than all cases because some were included in more than one category. * Statistically significant differences by chi-square test (p < 0.05) Page 138 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority (continued from page 137) suites since the onset of reporting in July that multiple facilities, such as a hospi- 2004. Survey responses were received tal and an ambulatory surgical facility, anesthetic block is recommended for this from 69 facilities, of which 29 indicated experienced a change in policies without separate perioperative procedure.1,2 The that they had implemented such a policy necessarily having an institutional experi- advantage or disadvantage of separately since reporting began and 2 indicated that ence with a wrong-site block. One of the marking the site of the regional anesthetic they had implemented such a policy prior wrong-site blocks following the implemen- block has been debated in theory but not to the onset of reporting. Among the 29 tation of the change in policy was in such tested in practice. The advantage is the facilities that had made a change, the time a facility. However, this facility had experi- value of the mark as a reference point. of the change ranged from the first quarter enced three wrong-site blocks prior to the The disadvantage is the potential to be of 2006 to the first quarter of 2014, with balanced preimplementation period, so mistaken for the surgical mark and lead the median being the first quarter of 2012. it actually experienced fewer blocks after to a wrong-site operation. In the absence These 29 facilities reported 25 wrong-site implementation of the change in policy, of evidence of the superiority of one anesthetic blocks before implementing albeit over a shorter total time. approach over the other, the Pennsylvania their policies and 5 after implementing Patient Safety Authority has not previ- As a result of the analysis based on these their policies. survey results, the Authority encourages ously commented on whether the regional anesthetic block site should be separately To balance the before and after times, facilities to consider developing polices marked. However, some departments of only a subset of reports submitted from within their anesthetic department to anesthesia, perhaps motivated by wrong- each facility for equal months before independently mark the regional block site blocks, have instituted policies of and after it implemented the change was sites. Considerations for such policies separately marking the site of a regional considered for comparative analysis. If a include the following: anesthetic block. facility implemented the change during —— The mark be placed after the sur- the first quarter of 2012, then the nine geon marks the surgical site as a The Authority conducted a survey to quarters under the new policy were com- determine how common the policy of reference and so as to not obscure pared with the last nine quarters under the surgeon’s mark. separately marking the regional anesthetic the old policy. During these balanced block site was in Pennsylvania and if —— The mark be placed after verifica- periods before and after the implementa- implementation of such a policy has been tion of the appropriate site for the tion of the change, the facilities reported associated with a reduction of reports of regional block with reconciliation of 12 wrong-site anesthetic blocks before the wrong-site blocks. all relevant information, including change and 3 after. Aside from 18 facili- the schedule, the surgical consent, At the end of the first quarter of 2014, ties that had no wrong-site procedures in the history and physician examina- the Authority sent a two-question survey either period and 1 that reported 1 wrong- tion, the patient’s understanding, to each acute care hospital and ambula- site procedure in each period, 9 had the surgeon’s site mark, and the tory surgical facility. The questions were fewer wrong-site blocks after initiating the anesthesia consent. as follows: change and 1 had more wrong-site blocks after initiating the change. This improve- —— The convention for the anesthetic 1. Does your medical facility have a block mark be identifiable as a mark policy or procedure that requires ment after implementation of the change in policy was statistically significant by for an anesthetic block and be dis- the anesthesia provider to mark tinct from the convention for the the anesthesia site where a regional the sign test (9/10, p < 0.05). No facility reported wrong-site surgery as a result of surgical site mark. or local anesthetic block will be erroneously referencing the site mark for —— The anesthetic block mark be refer- administered? the anesthetic block during the final time- enced in the prepped and draped 2. If yes, when was this policy or proce- field during the time-out for the out for the surgical procedure. dure implemented? anesthetic block. At the time of the survey, wrong-site It is possible that the results are biased as a result of an event precipitating an —— The anesthetic block mark not be anesthetic blocks were the most com- visible in the prepped and draped mon wrong-site procedures in operating immediate change in policy and increas- ing vigilance in the period following this surgical field. suites, accounting for 121 (21%) of the 571 wrong-site procedures in operating change. However, several changes were implemented at system levels, meaning Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 139 ©2014 Pennsylvania Patient Safety Authority U P DAT E NOTES 1. Pennsylvania Patient Safety Authority. 3. Clarke JR. Quarterly update: what might 4. Joint Commission. The universal protocol Principles for reliable performance of cor- be the impact of using evidence-based for preventing wrong site, wrong proce- rect-site surgery [online]. 2012 [cited 2014 best practices for preventing wrong-site dure, and wrong person surgery [online]. Jul 17]. http://patientsafetyauthority.org/ surgery? Pa Patient Saf Advis [online] [cited 2014 Jul 17]. http://www.jointcom- EducationalTools/PatientSafetyTools/ 2011 Sep [cited 2014 Jul 17]. http:// mission.org/assets/1/18/UP_Poster1.PDF PWSS/Documents/principles.pdf patientsafetyauthority.org/ADVISO 2. Quarterly update: the evidence base for RIES/AdvisoryLibrary/2011/sep8(3)/ best practices for preventing wrong-site Pages/109.aspx surgery. Pa Patient Saf Advis [online] 2010 Dec [cited 2014 Jul 17]. http:// patientsafetyauthority.org/ADVISO RIES/AdvisoryLibrary/2010/dec7(4)/ Pages/151.aspx Page 140 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 3—September 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 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. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania 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 Authority, 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 Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. 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 more than 40 years, ECRI Institute marries experience and indepen- dence 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 nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.