Wrong Person Surgery Research Articles

The prevalence and causes of wrong tooth extraction.

Dental extraction is a common procedure that is subject to complications and errors including extraction of the wrong tooth. This study aimed to determine the prevalence and identify the causes of wrong tooth extractions and explore the attitude of dentists after extraction of a wrong tooth. A questionnaire was adapted to fit the needs of this project and was distributed among all the dentists in four teaching dental clinics. The questionnaire was available in both the English and Arabic languages. Of the 486 questionnaires, 186 questionnaires were returned (response rate of 37%) and used for the analysis. The prevalence of wrong tooth extraction was 21.1%. The three most common reasons for extracting a wrong tooth were miscommunication (31.6%), inadequate referral (28.9%), and exhaustion of an overworked dentist (28.9%). Surprisingly, only 50% informed the patient and documented the incident in the patient's chart. Few dentists apologized to their patients or offered any kind of solution or compensation. Wrong tooth extraction is a prevalent yet preventable problem. Most of the common causes of this problem appear to be more system rather than individual related. There is a pressing need to implement the universal protocol for the prevention of wrong site, wrong procedure, and wrong person surgery.

The Key to Safety: Following Protocols.

The Key to Safety: Following Protocols.

Remote Video Auditing in the Surgical Setting

Remote video auditing, a method first adopted by the food preparation industry, was later introduced to the health care industry as a novel approach to improving hand hygiene practices. This strategy yielded tremendous and sustained improvement, causing leaders to consider the potential effects of such technology on the complex surgical environment. This article outlines the implementation of remote video auditing and the first year of activity, outcomes, and measurable successes in a busy surgery department in the eastern United States. A team of anesthesia care providers, surgeons, and OR personnel used low-resolution cameras, large-screen displays, and cell phone alerts to make significant progress in three domains: application of the Universal Protocol for preventing wrong site, wrong procedure, wrong person surgery; efficiency metrics; and cleaning compliance. The use of cameras with real-time auditing and results-sharing created an environment of continuous learning, compliance, and synergy, which has resulted in a safer, cleaner, and more efficient OR.

AIUM Practice Parameter for the Performance of Selected Ultrasound‐Guided Procedures

AIUM Practice Parameter for the Performance of Selected Ultrasound‐Guided Procedures

AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures

AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures

The WakeWings Journey: Creating a Patient Safety Program

AORN JournalVolume 103, Issue 6 p. 636-639 Column The WakeWings Journey: Creating a Patient Safety Program Elizabeth Mills MSN, RN, CNOR, CSSM, Elizabeth Mills MSN, RN, CNOR, CSSMSearch for more papers by this author Elizabeth Mills MSN, RN, CNOR, CSSM, Elizabeth Mills MSN, RN, CNOR, CSSMSearch for more papers by this author First published: 25 May 2016 https://doi.org/10.1016/j.aorn.2016.04.004 Editor's note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume103, Issue6June 2016Pages 636-639 RelatedInformation

Wrong Site Surgery—Where are We and What is the Next Step?

Wrong site surgery is estimated to occur 40 times per week in hospitals and clinics in USA. The universal protocol was implemented by the joint commission board of commissioners to address wrong site, wrong procedure, and wrong person surgery. The universal protocol has three principal components: preoperative verification, marking of the operative site, and a time-out. Despite this organized approach to this problem, current data do not demonstrate any progress. In fact some data suggest that the problem may be getting worse. It is apparent that a process relying on surgeon and surgical team memory is doomed to ultimate failure. Recommendations are made for a more in depth checklist process based on the recommendations of the World Health Organization, reports in the literature of known areas of weakness in the current process, and personal experience in hopes of establishing a more bullet proof system to avoid wrong site procedure.

A Survey of the Use of Time-Out Protocols in Emergency Medicine

Time-outs, as one of the elements of the Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery has been in effect since July 1, 2004. Time-outs are required by The Joint Commission for all hospital procedures regardless of location, including emergency departments (EDs). Attitudes about ED time-outs were assessed for a sample of senior emergency physicians serving in leadership roles for a national professional society. A survey questionnaire was administered to members of the American College of Emergency Physicians (ACEP) Council at the October 2009 ACEP Council meeting on the use of time-outs in the ED. A total of 225 (72%) of the 331 councilors present filled out the survey. Twenty-nine (13%) of respondents were unaware of a formal time-out policy in their ED, 79 (35%) reported that ED time-outs were warranted, and 5 (2%) reported they knew of an instance where a time-out may have prevented an error. Chest tubes (167 respondents [74%]) and the use of sedation (142 respondents [63%]) were most commonly identified as ED procedures that necessitated a time-out. Episodes of any wrong-site error in their EDs were reported by 16 (7%) of the respondents. Wrong patient (9 respondents [4%]) and wrong procedure (2 respondents [1%]) errors were less common. Although the time-out requirement has been in effect since 2004, more than 1 in 10 of ED physicians in this sample ofED physician leaders were unaware of it. According to the respondents, medical errors preventable by time-outs were rare; however, time-outs may be useful for certain procedures, particularly when there is a risk of wrong-site, wrong-patient, or wrong-procedure medical errors.

Experience of wrong-site tooth extraction among Nigerian dentists

To report the experience of wrong-site tooth extraction among Nigerian dentists. A self-administered questionnaire was distributed among a cross-section of Nigerian dentists. Information requested included personal experience on wrong-site tooth/teeth extraction and its after-effect, possible reasons for wrong-site tooth extraction and documentation of the event in patients' case. Respondents were also asked if they were aware of any colleagues who had previously experienced wrong-site tooth extraction and possible legal implication of the event, and if they aware of the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Twenty-two (13%) of the respondents reported having extracted a wrong tooth. The event occurred within 5years after graduation in most cases. Most respondents (53.6%) informed the patient immediately after the event. Only 68% of the respondents documented the event in patient's case record. Most common reasons for wrong-site tooth extraction were heavy workload, presence of multiple condemned teeth and miscommunication between dentists. Fifty-five percent of respondents were aware of a colleague who had extracted a wrong tooth. The most probable legal implication of wrong-site tooth extraction according to the respondents was litigation by the patient. Only 25% of dentists were aware of a universal protocol for preventing wrong-site surgery. Wrong tooth/teeth extraction is not an uncommon event in the studied environment. The need to be familiar with universal protocol on wrong-site surgery and its legal implications are highlighted.

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery

Background The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery was approved by the Joint Commission Board of Commissioners in July 2003 and became effective July 1, 2004. It requires the performance of a preprocedural verification process, marking of the procedure site, and performing a “time out” immediately before the start of a procedure. Compliance with the Universal Protocol requirements remains cumbersome because of the inherent characteristics of the surgical work flow process. Methods By working directly with the Joint Commission, their medical staff, perioperative nursing staff, and members of the hospital quality department, the authors were able to develop an innovative anatomic marking form, which serves as a surrogate for marking patients. Results The marking form has been used on 112,500 patients over 4.5 years, with a single implementation error that led to minimal patient harm. Conclusion This article describes the development of the anatomic marking form and the practical implications the process has on patient safety.

Sentinel Events

AORN JournalVolume 90, Issue 6 p. 926-929 Department Sentinel Events Donna S. Watson RN, MSN, CNOR, ARNP-BC, Donna S. Watson RN, MSN, CNOR, ARNP-BC Senior clinical educator Covidien, Fox Island, WASearch for more papers by this author Donna S. Watson RN, MSN, CNOR, ARNP-BC, Donna S. Watson RN, MSN, CNOR, ARNP-BC Senior clinical educator Covidien, Fox Island, WASearch for more papers by this author First published: 02 December 2009 https://doi.org/10.1016/j.aorn.2009.11.043Citations: 2 The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Donna S. Watson, column coordinator, by sending topic ideas tojournalcolumns@aorn.org. Editor's note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of the Joint Commission, Oakbrook Terrace, IL. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume90, Issue6December 2009Pages 926-929 RelatedInformation

Quality Improvement Guidelines for Preventing Wrong Site, Wrong Procedure, and Wrong Person Errors: Application of the Joint Commission “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” to the Practice of Interventional Radiology

THE membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such they represent a valid broad expert constituency of the subject matter under consideration for standards production.

The egocentric surgeon or the roots of wrong side surgery

> “Oh wad some power the giftie gie us > > To see the world as our patient sees it! > > It wad frae monie a blunder free us,...

Evidence for Practice

AORN JournalVolume 88, Issue S6 p. S109-S114 Evidence for Practice George Allen PhD, RN, CNOR, CIC, Search for more papers by this author George Allen PhD, RN, CNOR, CIC, Search for more papers by this author First published: 29 November 2008 https://doi.org/10.1016/j.aorn.2008.11.008 Editor's note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a registered trademark of the Joint Commission, Oakbrook Terrace, IL. Reprinted with permission from AORN J. 2007;86(5):868. This information is intended for general use only. The clinical implications are specific to the abstracted article only. Individuals intending to put these findings into practice are encouraged to review the original article to determine its applicability to their setting. Reprinted with permission from AORN J. 2007;86(6):1055–1056. Reprinted with permission from AORN J. 2007;86(6):1059–1060. Editor's note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a registered trademark of the Joint Commission, Oakbrook Terrace, IL. Reprinted with permission from AORN J. 2008;87(2):445–446. Reprinted with permission from AORN J. 2008;87(4):833–834. Reprinted with permission from AORN J. 2008;87(4):836–837. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Volume88, IssueS62009 OR Product DirectoryDecember 2008Pages S109-S114 RelatedInformation

Quality Improvement Guidelines for Preventing Wrong Site, Wrong Procedure, and Wrong Person Errors: Application of the Joint Commission “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” to the Practice of Interventional Radiology

THE membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such they represent a valid broad expert constituency of the subject matter under consideration for standards production.

Prevention of Wrong-Site Tooth Extraction: Clinical Guidelines

Wrong-site tooth extraction can be defined as the extraction of a tooth other than the one intended by the referring dentist. This adverse event continues to be one of the major reasons for filing malpractice claims against oral and maxillofacial surgeons. Most cases of wrong-site tooth extractions are preventable and can be minimized by the development of an educational program, an informative, unambiguous referral form, a pre-operative check list, and incorporation of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery into daily clinical practice.

Implementing the Universal Protocol Hospital-Wide

Beginning in July 2004, Joint Commission-accredited hospitals were required to adhere to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery by implementing time outs and site verifications for all invasive procedures. At Children's Hospital Boston, Mass, this requirement necessitated extensive editing of the existing time out and site verification policy and the development of a hospital-wide implementation plan. The Hospital's Universal Protocol champion developed an action plan that involved including nurse and physician representatives from each target area; rolling out the policy; creating materials for advertising the policy; and formulating an education, monitoring, and evaluation plan.

Correct patient, procedure, and site—Every time

AORN JournalVolume 85, Issue 6 p. 1061-1062 Department Correct patient, procedure, and site—Every time Mary Jo W. Steiert RN, BSN, CNOR, Mary Jo W. Steiert RN, BSN, CNOR AORN PresidentSearch for more papers by this author Mary Jo W. Steiert RN, BSN, CNOR, Mary Jo W. Steiert RN, BSN, CNOR AORN PresidentSearch for more papers by this author First published: 07 June 2007 https://doi.org/10.1016/j.aorn.2007.05.002 Editor's note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of the Joint Commission, Oakbrook Terrace, Ill. National “Time Out” Day is a service mark of AORN, Inc, Denver, Colo. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume85, Issue6June 2007Pages 1061-1062 RelatedInformation

SurgiChip—new technology for prevention of wrong site, wrong procedure, wrong person surgery

P b f The Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) universal protocal, part of their national patient safety goal to prevent wrong site, wrong procedure, and wrong person surgery, became effective on July 1, 2004. This guideline applies to all operative and other invasive procedures, including those done in settings other than the operating room such as endoscopy, imaging, emergency services, special procedures, etc. Standard PC.13.20 EP 9 of the JCAHO standards requires that “the site, procedure, and patient are accurately identified and clearly communicated using active communication techniques, during a final verification process such as a time-out before the start of any surgical or invasive procedure.” In response to this patient safety initiative, new technology has been developed.

Universal protocol for preventing wrong site, wrong procedure, wrong person surgery

EFFECTIVE JULY 1, 2004, compliance with the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery became required of all Joint Commission accredited organizations, to the extent that the requirements are relevant to the services provided by the organization. 1 Frequently asked questions about the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Available at: www.jcaho.org/accredited+organizations/patient+safety/universal+protocol/faq. Accessed July 2, 2004 Google Scholar As of July 1, it became mandatory for all members of the surgical team in accredited organizations to call a formal “time out” before starting the surgical procedure. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is designed to ensure that all personnel focus only on the patient just before the beginning of surgery to ensure that everyone agrees they are performing the right procedure on the right patient on the right site of the patient’s body. Nancy M. Saufl, MS, RN, CPAN, CAPA, is a Past President of the American Society of PeriAnesthesia Nurses. She is the coordinator of the Preadmission Testing Center at Florida Hospital-Memorial Division, Ormond Beach, FL.