Risk Of Wrong-site Surgery Research Articles

Minimizing the Risk of Wrong-Site Surgery.

Minimizing the Risk of Wrong-Site Surgery.

Photographic Confirmation of Biopsy Sites Saves Lives.

Quality photographic documentation of lesions prior to biopsy can decrease the risk of wrong site surgery, improve patient care, and save lives.

Preventing Wrong-Site Surgery in Oral and Maxillofacial Surgery.

This article discusses the risk for wrong-site surgery in oral and maxillofacial surgery and the development and utility of checklists. The intent of checklists and the specific applicability of each of them to ambulatory oral and maxillofacial surgery are presented. Checklists and other considerations to mitigate the risk of wrong-site surgery are evaluated. The role of interprofessional teams in improving patient care outcomes with the checklist as a vehicle is evaluated. Recommendations for the use of checklists and related methods in the ambulatory oral and maxillofacial surgery setting are made.

Venous infarction following surgery for chronic subdural hematoma: A lesson for us

Dear Sir, A 30-year-old male presented after 2 months of head injury with complaints of disorientation and poor feeding for last 4 days. He was initially treated at a local hospital. Computed tomography (CT) scan was done for the above complaint (after 55 days of head injury) in a private local diagnostic center, which was reported by a radiologist as lt hemispheric chronic subdural hematoma with mass effect. He was referred to our hospital as neurosurgery facility was not available there. On initial evaluation, he was responding to verbal commands but was not fully oriented to time, place, and person. He did not have any focal motor or sensory deficit. His pupils were bilaterally equal and reacting well to light. Neurological examination of his cranial nerves showed it to be within normal limits. We admitted the case after evaluating the patient and seeing the CT scan plate with report. He was planned for burr hole and evacuation under general anesthesia (GA). Burr hole was done over lt posterior parietal area, and dura was cauterized in a cruciate manner and nicked in the center. Profuse fresh bleeding occurred as dura was nicked. Suction over cotton piece reveled that brain matter was tightly attached to dura, with bleeding from a cortical vein, which was controlled by cauterizing the bleeding vein. When we rechecked the CT scan plate, to our surprise, we found that we had done a mistake by operating on the lt side whereas the lesion was on the rt side. Although chronic subdural hematoma was on the lt side of CT scan, the technician had marked that side as “r” [Figure 1]. Conventionally, rt side of CT scan is marked as “r,” but in this case, lt side of scan was marked as “r,” which confused us all, and the radiologist had reported it as lt side chronic subdural hematoma. Ultimately, another burr hole was done over rt posterior parietal area and the chronic subdural hematoma was evacuated. Figure 1 Technician had marked lt side of photo as “r.” According to the technician, it is rt side chronic subdural hematoma, but going by convention, the radiologist and surgeon thought it as lt side chronic subdural hematoma On the 2nd postoperative day, we did check scan. Underlying the first burr hole, there was an area of hypodensity suggesting associated venous infarct [Figure 2]. This infarction in post-op scan, which was absent in pre-op scan, might have appeared due to accidental injury to cortical vain due to our wrong decision of operating in the opposite side of lesion. Chronic subdural hematoma in the rt side had pushed the brain mater to the opposite side, thereby making it more vulnerable for injury. We had taken strong action not to repeat such an incident in the future. The diagnostic center and radiologist had been informed regarding such an incident and advised to take necessary steps. Figure 2 Underlying the first burr hole, there was an area of hypodensity suggesting associated venous infarct The case of wrong side being operated is a nightmare for surgeons. Such incidents happen so frequently that it is a significant risk for many surgeons during their professional career. Such types of cases are always underreported, the reason being obvious. Wrong-site surgery results from misinformation or misperception of the patient's orientation.[1,2] Some surgeons believe marking patient's operative site before surgery reduces such incidences, whereas others believe that marking is a limited method of preventing wrong-site surgery and may even increase the risk of wrong-site surgery. Discrepancies between history, clinical finding, and radiological finding should be analyzed and resolved prior to surgery. In cases like ours, where there was no localizing sign, we have to decide the side of lesion depending upon the scan finding. The reason behind reporting such an incident is that with widespread use of CT scan and the scan being done by untrained persons, such an incident is likely to occur with anyone. We have to be vigilant and not operate blindly by going through the radiologist's reports as they may be wrong. Whenever confusion arises between the reports and scan findings, it is better to discuss with the radiologist and get it cleared. The key to preventing wrong-site surgery is to have multiple independent checks of critical information before putting the knife over the scalp. We hope that our experience will be definitely helpful to others.

Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics?--Can the checklist help? Supporting evidence from analysis of a national patient incident reporting system.

BackgroundSurgical procedures are now very common, with estimates ranging from 4% of the general population having an operation per annum in economically-developing countries; this rising to 8% in economically-developed countries. Whilst these surgical procedures typically result in considerable improvements to health outcomes, it is increasingly appreciated that surgery is a high risk industry. Tools developed in the aviation industry are beginning to be used to minimise the risk of errors in surgery. One such tool is the World Health Organization's (WHO) surgery checklist. The National Patient Safety Agency (NPSA) manages the largest database of patient safety incidents (PSIs) in the world, already having received over three million reports of episodes of care that could or did result in iatrogenic harm. The aim of this study was to estimate how many incidents of wrong site surgery in orthopaedics that have been reported to the NPSA could have been prevented by the WHO surgical checklist.MethodsThe National Reporting and Learning Service (NRLS) database was searched between 1st January 2008- 31st December 2008 to identify all incidents classified as wrong site surgery in orthopaedics. These incidents were broken down into the different types of wrong site surgery. A Likert-scale from 1-5 was used to assess the preventability of these cases if the checklist was used.Results133/316 (42%) incidents satisfied the inclusion criteria. A large proportion of cases, 183/316 were misclassified. Furthermore, there were fewer cases of actual harm [9% (12/133)] versus 'near-misses' [121/133 (91%)]. Subsequent analysis revealed a smaller proportion of 'near-misses' being prevented by the checklist than the proportion of incidents that resulted in actual harm; 18/121 [14.9% (95% CI 8.5 - 21.2%)] versus 10/12 [83.3% (95%CI 62.2 - 104.4%)] respectively. Summatively, the checklist could have been prevented 28/133 [21.1% (95%CI 14.1 - 28.0%)] patient safety incidents.DiscussionOrthopaedic surgery is a high volume specialty with major technical complexity in terms of equipment demands and staff training and familiarity. There is therefore an increased propensity for errors to occur. Wrong-site surgery still occurs in this specialty and is a potentially devastating situation for both the patient and surgeon. Despite the limitations of inclusion and reporting bias, our study highlights the need to match technical precision with patient safety. Tools such as the WHO surgical checklist can help us to achieve this.

Transfer of a Pre-Operative Surgical Site Mark to the Opposite Side Increases the Risk of Wrong Site Surgery

Surgery performed at the incorrect anatomical site can be devastating for both patients and surgeons.1 We wish to highlight the case of a patient who had been correctly marked for surgery on the left hand with an arrow on the left forearm (Fig. 1: taken at the end of the procedure) who was found to also have an erroneous arrow on the right thumb (Fig. 2). On questioning the patient, it became clear that the arrow had become imprinted on the thumb when the patient had crossed his or her hands. Transfer of the mark not only introduces an erroneous mark, but also fades the correct mark. Figure 1 Left forearm correctly marked with an arrow. Figure 2 Arrow transferred to right thumb. The American Academy of Orthopedic Surgeons estimated that an orthopaedic surgeon has a 1 in 4 chance of performing wrong-site surgery during a 35-year career.2 Although there are anecdotal stories of transferred site marks we have identified only one previously published instance.3 This was in a patient whose mark was transferred from the forehead onto the bar of a slit lamp and then onto the brow of the next patient to use the lamp. The use of marker pens does present a small risk in these circumstances of which all users should be aware. Guidelines on pre-operative marking have been produced by The Royal College of Surgeons of England in conjunction with the National Patient Safety Agency4 and feature in the World Health Organization's Surgical safety checklist.5