U P DAT E S Quarterly Update on Wrong-Site Surgery: Electronic Records Can Help Prevent Harm but Are Not Harmless John R. Clarke, MD There were eight event reports of wrong-site surgery in Pennsylvania operating rooms Editor Emeritus, Pennsylvania Patient Safety Advisory (ORs) during the third quarter of 2014 and two reports belatedly confirmed from a Clinical Director Emeritus, Pennsylvania Patient Safety Authority prior quarter (see the Figure). The eight reports matched those of the second-lowest Professor of Surgery, Drexel University quarter ever and were the lowest number of reports for the beginning of an academic year (July through September). Six of the reports involved injections: one unwanted preoperative regional block, one preoperative regional block done on the wrong side and attributed to the lack of an “all stop” time-out, two wrong-side pain injections, and two preliminary local blocks by the surgeons prior to any time-outs, as noted below: Surgeon preinjected the right ear instead of the left ear per consent. He realized his mis- take as he was preparing to drape the patient. Prior to [the surgeon] coming into the room, the patient’s left foot was put up on a prep pillow and wrapped with Webril™. This was the nonoperative side. When the surgeon came into room, he proceeded to inject that foot. He injected 1 mL. [Then, he] stopped and questioned which side we were working on, and the nurse said the right. . . . The right foot was then prepared for injection, and the procedure was completed as scheduled. Two reports were of surgery on the wrong finger. One was related to accepting nonspe- cific information on the consent and from the patient: Patient’s surgical consent read “trigger finger release right.” When the circulator asked the patient what he was having done, the patient replied, “I’m having one of my right trigger fingers released. I need them all done.” While the patient was making the previous statement, he was pointing to the mark identified by both the patient and the surgeon in the holding area, which was located below his right third finger. Documentation reflected patient’s initial complaint in the surgeon’s office was of his right trigger thumb. Numerous near-miss reports continue to demonstrate persistent areas of risk and the effectiveness of practices that prevent wrong-site surgery.1,2 This past quarter, more than a dozen procedures were scheduled incorrectly, with potential downstream ramifications: Patient in holding area; wrong side on consent for surgery and OR schedule. Left side was indicated on consent as well as on the OR schedule, when it is the right side that needs the surgery. Discussed with family (patient is demented), who did not know which side. It was found by reading the HP [history and physical], which indicated it was the right foot that was injured. . . . The old consent was discarded and a new consent obtained. The [scheduling] error was not discovered until the patient entered the OR, where the RN picked up on the discrepancy. . . . Although the pre-op holding RN did check the schedule, he did not notice the scheduling discrepancy. More than 30% of the incorrectly scheduled cases documented the surgeon’s office as the source of error: The case information was forwarded to the chair[person], who discussed it with [the surgeon] because this was the third case this year from that office that a procedure site was scheduled incorrectly. Scan this code The office scheduling sheet was pulled and clearly states left. . . . The patient was with your mobile marked for the correct side that corresponded with the consent, the right [side]. device’s QR reader to access the Monitoring the accuracy of information from surgeons’ offices is important because Authority's toolkit 11% of all wrong-site operations can be traced back to incorrect information from sur- on this topic. geons’ offices.3,4 Page 172 Pennsylvania Patient Safety Advisory Vol. 11, No. 4—December 2014 ©2014 Pennsylvania Patient Safety Authority Figure. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by OR instead of [third patient on sched- Academic Year ule] . . . because the third patient’s NUMBER family had just taken her CPAP OF REPORTS Jul to Sep Oct to Dec Jan to Mar Apr to Jun [continuous positive airway pressure] 80 equipment back to their car. CRNA did not notify the surgeon, the OR 21 team, or the preoperative nurse that 60 19 she was taking a patient out of order. 8 16 14 11 9 A physician called the OR to schedule 17 21 16 40 11 10 an emergency C-section on a patient 16 18 16 14 19 but did not mention the patient’s 15 11 17 13 name or room number. The nurs- 17 16 13 10 20 13 11 15 ing supervisor was notified, and she 23 23 6 11 provided the wrong patient’s name 19 17 MS14647 16 16 16 13 and room number. The OR was 11 10 8 0 scheduled under the wrong patient’s name. During the surgical time-out, 5 6 7 8 9 0 1 2 3 4 5 -0 -0 -0 -0 -0 -1 -1 -1 -1 -1 -1 staff discovered the wrong patient had 04 05 06 07 08 09 10 11 12 13 14 been scheduled due to misinformation 20 20 20 20 20 20 20 20 20 20 20 by the nursing supervisor. The correct ACADEMIC YEAR patient was in the OR. In at least three reports, the information Fortunately, providers receiving patient Surgeons are not always doing a proper on the white board in the OR was incor- information check for discrepancies and preoperative verification of the docu- rect prior to the time-out: identify them as soon as discovered for ments, with confirmation by the patient: reconciliation by the surgeon, based on Patient and paperwork confirms [Surgeon] entered the room while primary sources of information: cataract surgery on the left eye. Dry- the patient was being fitted for a erase board lists cataract surgery on Schedule did not have full procedure TLSO [thoracolumbar sacral ortho- the right eye. Dry-erase board changed listed. Called to PAT [preadmission sis] brace. The [surgeon] did not to reflect the correct eye. This was testing] department to have schedule identify the patient and proceeded changed before the “time-out.” corrected prior to the day of surgery. to dilate the incorrect patient’s eye [preoperatively]. Surgeons do not always participate in At least 10 consents were incomplete or a time-out: inaccurate, some to an extent suggest- Patient arrived in the OR visibly ing that the informed consents were not concerned. Patient stated that a doc- Physician began surgery without obtained by the surgeons: tor came into her room in the holding doing a time-out. This was realized area . . . and marked her left hip approximately six minutes into the Surgical consent did not list any for hip surgery. The patient is not procedure, and the time-out was procedure to be performed. Patient here today for hip surgery and was completed. already given sedating medicines. concerned arriving to the OR if she Two reports illustrate the difference When verifying the procedure with was going to receive the correct care. between a properly done time-out and a the patient, the patient reported that I went over her consent with her in poorly done time-out: he was having an appendectomy. The great detail, and she agreed that she consent indicated “laparoscopic, pos- was here to have neck surgery. Patient was having right knee surgery. sible open, cholecystectomy.” The tourniquet was applied on the The correct identities of at least four left leg. The patient was prepped and Preregistration came from office patients were ascertained only by checking draped for left knee surgery. During clearly stating “carpal tunnel the patients’ identifiers in the preopera- time-out, it was confirmed that the release.” Registration entered tive holding areas or ORs: right knee was the operative knee. “Colonoscopy.” . . . Consent stated CRNA made decision to take The drapes were removed and the cor- the incorrect procedure. fourth patient on schedule back to rect leg was prepped and draped. Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 173 ©2014 Pennsylvania Patient Safety Authority U P DAT E S CRNA was relieved for a break min- A review of the near-miss reports from Analysts reviewed the complete registry utes before the time-out. One of the this past quarter identified the following: of 596 wrong-site operations. There elements of the time-out is [verifying Patient stated operative site is left were 12 wrong-site procedures based on that] the antibiotics are given. Two leg. MD consent identified left leg. another patient’s information, a con- grams of Ancef ® were ordered, and NaviCare system and Epic system tributing factor that is not unique to an . . . none had been documented. . . . indicate right leg. Site confirmed and electronic record: I . . . gave the patient the 2 grams performed on correct leg. — A pathology report of cancer, attrib- at 0936. . . . When [the CRNA] uted to the wrong patient during returned from her break, I asked her During the time-out, the image of the consent would not load on the com- dictation, was the basis for surgery. to reverify the time the Ancef was puter. Attempts to print the consent — Wrong radiographs were used to given, and she reported that she had were not successful. Staff had visually localize the lesion. given the patient 2 grams at 0904. seen the consent prior to the time-out, — Another patient’s H&P was misla- ELECTRONIC RECORDS: ARE THEY and the procedure was completed beled, incorrectly included in the due to the high risk of awakening the chart, and used as the basis for ALWAYS HELPFUL? patient and a delay of the surgery. the procedure. In theory, electronic records can help — Another patient’s consent was mis- Patient was prepped and draped for implement evidence-based best practices labeled in the surgeon’s office and a left partial nephrectomy. Surgeon to prevent wrong-site surgery.1,2 Electronic incorrectly included in the chart. halted the surgery due to inconsis- scheduling can ensure that the specific tency with radiology films that were — The surgeon called his office and got site is included when an operation is displayed in the operating room. The incorrect information from the office scheduled. Electronic records are more charge nurse and administrators were charts. (Presumably, this communica- accessible by everyone who is in a position then notified of the situation. Surgeon tion error might not have occurred to identify discrepancies among the docu- reevaluated the radiology films and with compatible electronic office ments in the preoperative period. Primary report and determined that incorrect records.) source documents are more readily acces- films were placed in patient’s [elec- — The patient was accompanied by sible when reconciliation of discrepant tronic medical] records. Surgeon . . . another patient’s chart. documents is necessary. In the OR, all determined that the left kidney was — The patient, identified by passive documents can be displayed on monitors [nevertheless] the correct kidney. query, was the wrong patient. that are visible to the entire OR team. Intraoperative verification by radiographic All surgical paperwork on the chart — The patient was operated on out of confirmation can be done more rapidly by stated right carpal tunnel release, order without any identifiers both the surgeon and radiologist. which was correct. H&P [history and or verification. physical] stated left carpal tunnel — In the OR, the surgeon consulted In response to the following edited query release. Pre-op nurse noted the dis- the wrong patient’s office chart. from a facility, the Pennsylvania Patient crepancy prior to the admission of the Safety Authority looked for events impli- — Three patients were confused with patient to pre-op. Correct H&P was cating electronic records: other patients with the same name located in the patient’s electronic medi- I’m looking for any best practices that and similar problems. are available that discuss the inclu- cal record. Patient had a left carpal sion of validating that the correct EMR tunnel release performed prior to this One patient received a different proce- [electronic medical record] is open/ dure than intended as a result of staff selected as part of the surgical time- date of surgery, and preadmitting test- out process. Currently our time-out ing pulled the wrong H&P from the accessing the wrong information electroni- policy does not address the validation [patient’s electronic] medical record. cally. He had consented to a procedure. of the correct anesthesia and OR The consent was in the electronic system. EMR as part of the surgical time-out. The Authority hypothesized that elec- Has the Pennsylvania Patient Safety He then changed his mind and requested Authority received any events related tronic systems were capable of having a different procedure. The consent for to the incorrect anesthesia or OR EMR incorrect information entered, just like that procedure was in the electronic sys- being used for documentation of the paper records. It also hypothesized that care of the surgical patient although tem; however, there was no mechanism the patient and procedure were cor- electronic systems could make it easier for labeling the original consent as void rect and verified through consents and to access archaic or outdated information, and superseded by the second consent. patient identifiers? when more recent information is The original consent was accessed more accurate. Page 174 Pennsylvania Patient Safety Advisory Vol. 11, No. 4—December 2014 ©2014 Pennsylvania Patient Safety Authority electronically and used as the reference patient’s record or the incorrect patient’s the patient and the date of the document for the intended procedure. record are possible with both paper and are easily identified in electronic records. The Authority concludes that wrong-site electronic records. Outdated information Additionally, consider an electronic errors due to incorrect information in the may be easier to access electronically. method for time-stamped notations for Consider making sure that the name of corrections of information. NOTES 1. Pennsylvania Patient Safety Authority. 2010 Dec [cited 2014 Jul 17]. http:// 4. Pennsylvania Patient Safety Authority. Principles for reliable performance of cor- patientsafetyauthority.org/ADVISO Monitoring of preoperative information rect-site surgery [online]. 2012 [cited 2014 RIES/AdvisoryLibrary/2010/dec7(4)/ from surgeon’s office available at first Jul 17]. http://patientsafetyauthority.org/ Pages/151.aspx encounter [online]. 2012 [cited 2014 Nov EducationalTools/PatientSafetyTools/ 3. Clarke JR. Is your office helping you 6]. http://patientsafetyauthority.org/Edu PWSS/Documents/principles.pdf prevent wrong site surgery? Bull Am Coll cationalTools/PatientSafetyTools/PWSS/ 2. Quarterly update: the evidence base for Surg 2014 Apr;99(4):28-31. Also available Documents/office_monitor.pdf best practices for preventing wrong-site at http://bulletin.facs.org/2014/04/ surgery. Pa Patient Saf Advis [online] is-your-office-helping-you-prevent-wrong- site-surgery Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 175 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 4—December 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.