One opportunity for errors to occur that could lead to wrong site/wrong patient surgery is when surgical cases are “booked”. A new paper (Cima 2010) looked at the frequency of errors in the surgical case listing at a large academic medical center and found such errors in 1.38% of cases. Fortunately, there were no cases of wrong site/wrong patient surgery in their organization because the errors were picked up by a variety of healthcare workers preoperatively or in the OR. But the sheer number of cases with errors in booking highlights the serious potential during his step to set the stage for a wrong site surgery to occur.
They found that missing laterality was the most common error (66%), followed by incorrect laterality (14%) and incorrect listing besides laterality (11%). Such listing errors were found across the gamut of surgical specialties.
The findngs prompted the organization to revise its procedures for surgical case listing. They implemented an electronic surgical listing system using standardized case descriptions that required input of the laterality. Implementation of that system in ob/gyn surgery reduced the frequency of errors from 1.50% to 0.54% and in colorectal surgery from 2.06% to 0.49%.
We recommend you do this sort of audit in your organization to see what your potential vulnerability is during the booking process. Equally importantly, look at how your other “defenses” would pick up such potential problems prior to surgery. Are 100% of your cases reviewed the day prior to surgery by healthcare workers trained to identify such errors? Any case not reviewed until the day of surgery is one step closer to being a sentinel event. Who do you allow to book cases? Do you require formal designation of laterality at the time of booking? How do you ensure that all cases with imaging findings have laterality reconciliation prior to surgery?
The Joint Commisssion. Universal Protocol. Updated 2010.
WHO Surgical Safety Cheklist
Cima RR, Hale C, Kollengode A, et al. Surgical Case Listing Accuracy: Failure Analysis at a High-Volume Academic Medical Center. Arch Surg. 2010; 145(7): 641-646