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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