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Patient Safety Tip of the Week
September 10,
2024
Scheduling and
Informed Consent Contribute to Wrong-Site Surgery
Weve discussed how
surgical scheduling and informed consent can contribute to wrong-site surgery
in many columns (see, for example, our Patient Safety Tips of the Week for October
30, 2012 Surgical Scheduling Errors and September 10, 2013 Informed Consent and Wrong-Site Surgery).
Now Taylor et al. (Taylor
2024) have taken a deep dive into
the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to see how
these two processes contribute to wrong-site surgery.
Over a four-year
period from January 2019 through December 2022, the authors found 1,166 event
reports that described a consent and/or schedule error. 86% of the reports were
from hospitals and 14% were from ambulatory surgery facilities (ASFs). Among
the 1,166 reports, 56% described a schedule error, 34% had a consent error, and
10% involved both error types. Scheduling errors were slightly more frequent at
hospitals than ASFs (58% vs. 49%). At hospitals wrong-side schedule errors
(42%) were reported twice as often as the wrong-side consent errors (21%). But
at ASFs, the percentage of wrong-side schedule errors (25%) and wrong-side consent
errors (23%) were similar.
In the sample of
reports, the frequency of error subtypes were: wrong side
(69%), wrong procedure (24%), wrong site (4%), and wrong patient (3%). The
analysis also revealed similarities and differences in the distribution of
error types and subtypes across hospitals and ASFs.
Wrong-side errors
were reported 14 percentage points more at hospitals than at ASFs, but wrong
procedure errors were 18 percentage points higher at ASFs than at hospitals
(40% vs. 22%).
The article has a
nice table listing risk factors for errors in informed consent or scheduling or
both. Examples include things like the consent being obtained by someone other
than the attending provider or a patient (or representative) consenting to
erroneous information. Some examples of scheduling errors involved the
scheduler not confirming information from primary documents, receiving only a
verbal order, booking multiple cases, or being insufficiently knowledgeable
about clinical issues. In the past, weve stressed that last item. All too
often, a non-clinical person in a physicians office rather than the physician
is the person calling in to the hospital or ASF to schedule a case. The table
also notes that paper or electronic forms that allow open text may be
problematic and that disparities often occur when both electronic and paper
forms are used. The table also includes examples related to handwriting,
abbreviations, and communication.
The Taylor article
provides a table listing 33 strategies to mitigate the risk of consent of
scheduling errors. Youll need to go to the article itself for all 33, but
well mention a few key strategies:
·
Consent
should always be obtained by the attending provider.
·
All
primary source records should be easily available to staff while consent is
obtained.
·
The
patient (or representative) should use sayback or
readback during consent.
·
Standardized
forms should be used and electronic ones can avoid
handwriting errors.
·
Scheduling
should be done by someone knowledgeable about the procedure and other relevant
clinical content.
·
Orders
for a procedure should be in written form (and when a verbal order must be
given, it should be done with readback and hearback.
·
In the
patient records, the provider should provide sufficient details about the
indication, recommended procedure, site, and side.
·
Only
approved abbreviations (or none at all) should be
allowed.
Many of both the
risks and the mitigation strategies in the Taylor paper were previously
detailed in our Patient Safety Tips of the Week for October 30, 2012 Surgical Scheduling Errors and
September 10, 2013 Informed Consent and Wrong-Site Surgery. The Taylor study is an important
contribution to our understanding of factors contributing to wrong-side
surgery. Wrong-site surgery continues to occur despite all our patient safety
efforts. Its clear that errors in both the informed consent and scheduling
procedures contribute to wrong-site surgery. Its time that all parties
involved give the same undivided attention to these procedures as we give to
the surgical timeout.
Some of our prior columns related to wrong-site surgery:
September 23, 2008 Checklists
and Wrong Site Surgery
June 5, 2007 Patient
Safety in Ambulatory Surgery
July 2007 Pennsylvania
PSA: Preventing Wrong-Site Surgery
March 11, 2008 Lessons
from Ophthalmology
July 1, 2008 WHOs
New Surgical Safety Checklist
January 20, 2009 The
WHO Surgical Safety Checklist Delivers the Outcomes
September 14, 2010 Wrong-Site
Craniotomy: Lessons Learned
November 25, 2008 Wrong-Site
Neurosurgery
January 19, 2010 Timeouts
and Safe Surgery
June 8, 2010 Surgical
Safety Checklist for Cataract Surgery
December 6, 2010 More
Tips to Prevent Wrong-Site Surgery
June 6, 2011 Timeouts
Outside the OR
August 2011 New Wrong-Site Surgery Resources
December 2011 Novel Technique to Prevent Wrong Level Spine
Surgery
October 30, 2012 Surgical Scheduling Errors
January 2013 How Frequent are Surgical Never Events?
January 1, 2013 Dont Throw Away Those View Boxes Yet
August 27, 2013 Lessons on Wrong-Site Surgery
September 10, 2013 Informed Consent and Wrong-Site Surgery
July 2014 Wrong-Sided Thoracenteses
March 15, 2016 Dental
Patient Safety
May 17, 2016 Patient
Safety Issues in Cataract Surgery
July 19, 2016 Infants
and Wrong Site Surgery
September 13, 2016 Vanderbilts
Electronic Procedural Timeout
May 2017 Another
Success for the Safe Surgery Checklist
May 2, 2017 Anatomy
of a Wrong Procedure
June 2017 Another
Way to Verify Checklist Compliance
March 26, 2019 Patient
Misidentification
May 14, 2019 Wrong-Site Surgery and
Difficult-to-Mark Sites
May 2020 Poor
Timeout Compliance: Ring a Bell?
September 14, 2021 Wrong Eye Injections
October 5, 2021 Wrong Side Again
November 9, 2021 Ensuring Safe Site Surgery
February 15, 2022 Wrong-Side Chest Tubes
May 2022 PPSA:
Updated Wrong-Site Surgery Recommendations
June 13, 2023 Preventing Wrong-Site
Surgery
November 2023 Importance
of Timeouts Outside the OR
January 30, 2024 Is Your Surgical Safety
Checklist Working?
References:
Taylor MA, Yonash RA. Risk Factors
for Wrong-Site Surgery: A Study of 1,166 Reports of Informed Consent and
Schedule Errors. Patient Safety 2024; 6(1): 117084
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