Incidence Of Wrong-site Surgery Research Articles

Review of Smartphone Applications Repurposed to Help Reduce the Incidence of Wrong Site Surgery.

Tulane University School of Medicine, New Orleans, Louisiana Department of Dermatology, State University at Buffalo School of Medicine, Buffalo, New York Department of Dermatology, State University of New York, Buffalo, New York The authors have indicated no significant interest with commercial supporters.

Wrong-Site Surgery in Orthopaedics: Prevalence, Risk Factors, and Strategies for Prevention.

The incidence of wrong-site surgery in orthopaedics is unknown. This is due to a lack of data regarding the exact numbers of surgical procedures performed and a lack of a uniform mandatory error reporting infrastructure. Twenty-one percent of hand surgeons, 50% of spinal surgeons, and 8.3% of knee surgeons surveyed have reported performing at least one wrong-site surgery during their career. Every orthopaedic surgeon, no matter his or her orthopaedic subspecialty, is at risk for completing a wrong-site surgery during his or her career. Prevention of wrong-site surgery should remain a priority for the orthopaedic community. Surgeon leadership, commitment, and vigilance are critical to improve patient safety by ensuring that validated safety processes are used in all orthopaedic settings including effective surgical team communication, checklists, and routine collection and analysis of quality and safety data.

Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events.

Serious, preventable surgical events, termed never events, continue to occur despite considerable patient safety efforts. To examine the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires in the era after the implementation of the Universal Protocol in 2004. We searched 9 electronic databases for entries from 2004 through June 30, 2014, screened references, and consulted experts. Two independent reviewers identified relevant publications in June 2014. One reviewer used a standardized form to extract data and a second reviewer checked the data. Strength of evidence was established by the review team. Data extraction was completed in January 2015. Incidence of wrong-site surgery, retained surgical items, and surgical fires. We found 138 empirical studies that met our inclusion criteria. Incidence estimates for wrong-site surgery in US settings varied by data source and procedure (median estimate, 0.09 events per 10,000 surgical procedures). The median estimate for retained surgical items was 1.32 events per 10,000 procedures, but estimates varied by item and procedure. The per-procedure surgical fire incidence is unknown. A frequently reported root cause was inadequate communication. Methodologic challenges associated with investigating changes in rare events limit the conclusions of 78 intervention evaluations. Limited evidence supported the Universal Protocol (5 studies), education (4 studies), and team training (4 studies) interventions to prevent wrong-site surgery. Limited evidence exists to prevent retained surgical items by using data-matrix-coded sponge-counting systems (5 pertinent studies). Evidence for preventing surgical fires was insufficient, and intervention effects were not estimable. Current estimates for wrong-site surgery and retained surgical items are 1 event per 100,000 and 1 event per 10,000 procedures, respectively, but the precision is uncertain, and the per-procedure prevalence of surgical fires is not known. Root-cause analyses suggest the need for improved communication. Despite promising approaches and global Universal Protocol evaluations, empirical evidence for interventions is limited.

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system

Although wrong-site surgery has garnered extensive scrutiny, the incidence of wrong-site blocks remains unknown. Our study thus sought to quantify the incidence of wrong-site blocks and examine some of their associated risk factors in our multihospital health-care system. Using quality-improvement and billing data, we quantified the total number of blocks and wrong-site blocks occurring between July 1, 2002 and June 30, 2012 within the University of Pittsburgh Medical Center Health System. The incidence of wrong-site block was determined by block type, hospital, and type of service involved in performing the block. The incidence of wrong-site block was compared with that of wrong-site surgery. Fisher's exact tests were performed to determine associations between the incidence of wrong-site block and any of the aforementioned variables. A root-cause analysis was performed to determine the source of wrong-site blocks after the implementation of a timeout policy. Of the 85 915 patients receiving blocks, 70 441 received only unilateral blocks, yielding an overall incidence of wrong-site block of 1.28 (95% confidence interval 0.43-2.13) per 10 000 patients receiving unilateral blocks. The incidence of wrong-site block was highest with femoral blocks, and differed from the incidence of wrong-site surgery. All occurrences of wrong-site block after the implementation of the timeout policy involved policy violations. Our study provides the first incidence data on wrong-site block in a large patient population and can help hospitals to develop policies based on these data. It is yet to be determined whether active intervention can eliminate this adverse event.

The Patient First. Above All Do No Harm (Primum Non Nocere)

No caring and responsible physician or surgeon knowingly wants to harm a patient…to be responsible for a medical or surgical error…yet now, more than twelve years after the Institute of Medicine’s report drawing national attention to errors, the incidence of errors and reported harm to patients continues1. Every physician and surgeon should ask themselves why, and they should feel obligated to avoid medical and surgical mistakes in their practices and hospitals. To date, altruism and professionalism haven’t worked, pay-for-performance programs haven’t worked, and regulations haven’t worked2. Estimates of avoidable injuries and deaths remain unchanged or are increasing, and readmissions remain unchanged at 15% to 24%3. Hospitals only voluntarily report errors, and these reports yield an error rate of about 1%. However, using a global trigger tool, the Institute of Healthcare Improvement estimates that the rate of adverse events is ten times the voluntarily reported rate4. Except in hospitals that strictly enforce a preoperative time-out and require the surgeon to sign the correct surgical site, the incidence of wrong-site surgery is increasing5. Why do we keep doing the same things over and over again and expect a different result? Lucian Leape believes that there has been some progress in the patient safety movement6. We now have safe practices for both process and system …

Patient safety in spine surgery: regarding the wrong-site surgery.

Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your site program by the American Academy of Orthopedic Surgeon, the sign, mark and X-ray program by the North American Spine Society, and the Universal Protocol program by the Joint Commission, the incidence of wrong-site surgery has not decreased. To prevent wrong-site surgery in spine surgeries, the spine surgeons must put patient safety first, complying with the hospital policies regarding patient safety. In the operating rooms, the surgeons need to do their best to level the hierarchy, enabling all to speak up if any patient safety concerns are noted. Changing the operating room culture is the essential part of the patient safety concerning spine surgery.

Crew Resource Management: Using Aviation Techniques to Improve Operating Room Safety

Since the publication of the Institute of Medicine report estimating nearly 100,000 deaths per year from medical errors, hospitals and physicians have a renewed focus upon error reduction. We implemented a surgical crew resource management (CRM) program for all operating room (OR) personnel. In our academic medical center, 19,000 procedures per year are performed in 27 operating rooms. Mandatory CRM training was implemented for all peri-operative personnel. Aviation techniques introduced included a pre-operative checklist and brief, post-operative debrief, read and initial files, and various other aviation-based techniques. Compliance with conduct of the brief/debrief was monitored as well as wrong-site surgeries and retained foreign body events. The malpractice insurance database for claims was also queried for the period prior to and after training. Initial training was accomplished for 517 people, including all anesthesiologists, surgeons, nurses, technicians, and OR assistants. Pre-operative briefing increased from 6.7 to 99% within 4 mo. Wrong site surgeries and retained foreign bodies decreased from a high of seven in 2007 to none in 2008, but, after 14 mo without additional training, these rose to five in 2009. Malpractice expenses (payouts and legal fees) totaled $793,000 (2003-2007), but have been zero since 2008. CRM training and implementation had an impact on reducing the incidence of wrong site surgery and retained foreign bodies in our operating rooms. However, constant reinforcement and refresher training is necessary for sustained results. Though no one technique can prevent all errors, CRM can effect culture change, producing a safer environment.

Outcome of 6 years of protocol use for preventing wrong site office surgery

Patient safety is emerging as an integral part of the overall strategy to improve health care in the United States. Wrong site surgery is correctly noted to be a sentinel event and great efforts must be made to avoid it. We sought to determine the incidence of wrong site surgery after implementation of a preoperative protocol in patients presenting for treatment of skin cancer at a high-volume, Joint Commission-accredited, tertiary referral center for dermatologic surgery. A retrospective chart review was performed of 7983 cases performed on patients presenting for treatment of skin cancer in the office setting. There were no cases of wrong site surgery. There were, however, 18 cases of failure to identify the original biopsy site (cancer site). This was a retrospective study done at one cancer center. Integration of a correct surgery site protocol into a daily patient care model is a useful step in preventing occurrences of wrong site dermatologic surgery.

Incidence of Wrong-Site Surgery Among Foot and Ankle Surgeons

In 1998, the American Academy of Orthopaedic Surgeons initiated the "sign your site" campaign to address the issue of wrong-site surgery (WSS). Using a confidential online survey sent to 1094 active members of the American Academy of Foot and Ankle Surgeons, the authors assessed participation in the "sign your site" campaign and the occurrence of WSS encountered during their careers. A total of 319 responses were received (response rate = 29.2%). In all, 41 of 310 respondents (13%) reported performing WSS at least once, with 4 surgeons (1%) reporting the occurrence twice in their careers; 70 of 310 (23%) surgeons reported that they had prepped the wrong surgical site, but the error was recognized prior to making an incision. In all, 302 of 309 respondents (97.7%) reported that they were aware of the "sign your site" initiative. Since the introduction of the campaign, significantly more (89.2% vs 49.2%) foot and ankle surgeons routinely mark the surgical site (P < .001). The Joint Commission revised the universal protocol for surgical site verification requiring an individual directly involved in a surgical procedure to mark the site as of January 1, 2009. The authors believe this revision will lower the incidence of WSS further.

Surgical Time Outs in a Combat Zone

AORN supports the Joint Commission's requirements and guidelines to promote correct site surgery, including preoperative verification, site marking, and conducting and documenting a surgical time out. This article highlights the success of a well-implemented surgical time out policy and procedure at a two-bed combat support hospital in northern Iraq. Policy implementation, training, documentation, and quality management chart checks prevented any incidence of wrong site surgery through the completion of more than 900 procedures on more than 400 patients during a 15-month period.

Incidence of Wrong-Site Surgery Among Hand Surgeons

Incidence of Wrong-Site Surgery Among Hand Surgeons