Wrong-side thoracentesis: lessons learned from root cause analysis.

Abstract

Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences. To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with their occurrence. We searched the National Center for Patient Safety database for wrong-side thoracenteses performed in ambulatory clinics and hospital units other than the operating room reported from January 1, 2004, through December 31, 2011. Data extracted included patient factors, clinical features, team structure and function, adherence to bottom-line patient safety measures, complications, and outcomes. Fourteen cases of wrong-side thoracenteses are identified. Contributing factors included failure to perform a time-out (n=12), missing indication of laterality on the patient's consent form (n=10), absence of a site mark on the patient's skin within the sterile field (n=12), and absent verification of medical images (n=7). Complications included pneumothoraces (n=4), hemorrhage (n=3), and death directly attributable to the wrong-side thoracentesis (n=2). Teamwork and communication failure, unawareness of existing policy, and a deficit in training and education were the most common root causes of wrong-side thoracentesis. Prevention of wrong-site procedures and accompanying patient harm outside the operating room requires adherence to the Universal Protocol and time-outs, effective teamwork, training and education, mentoring, and patient assessment for early detection of complications. The time-outs provide protected time and place for error detection and recovery.