What’s New in the Patient Safety World
July 2007
Pennsylvania Patient Safety Authority: Preventing Wrong-Site Surgery
The
June 2007 issue of the Patient Safety Advisory from the Pennsylvania Patient Safety
Authority has an outstanding article on wrong-site surgery and the
factors that may predispose to it.
There
is an accompanying video presentation on “Doing the ‘Right’ Things to Correct
Wrong-Site Surgery” and also a tip sheet for consumers.
The
Pennsylvania experience suggests that wrong-site surgery is much more common
than previously estimated. Their event reporting system differs from others in
that near-misses are also reported so, unlike most other reporting systems,
cases where no harm came to patients do get reported. Hence, the Pennsylvania
experience is probably a much truer reflection of the incidence of wrong-site
surgery. About a third of all Pennsylvania acute hospitals have reported cases
of wrong-site surgery and there is an average of one wrong-site report per year
for a 300-bed hospital.
The
report lists numerous examples of cases of wrong-site surgery, sorted according
to the types of factors that predisposed to the events. It then provides a
thorough review of the predisposing factors, types of errors, and potential
solutions, based not only on the Pennsylvania experience but also on a
comprehensive review of the literature.
It
discusses the Joint Commission Universal Protocol as well as multiple other
safe-site protocols that are used (see also our March 2007 “What’s New” column)
and provides references to multiple tools and resources available through many
organizations to help prevent wrong-site surgery.
Kudos
to John Clarke, M.D. and his team at the Pennsylvania Patient Safety Authority
for this great contribution! This is truly a must-read for anyone involved in
healthcare, regardless of whether they do surgery or not.
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