Wrong Side Surgery Research Articles

Patient safety in the operating room at a governmental hospital

Patient safety is a fundamental principle of healthcare; it is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical errors that often lead to adverse healthcare events. The aim of this study is to aid any hospital in attaining better quality of patient care in the operating room (OR) by achieving patient safety according to the WHO safety guidelines. Specific objectives include the assessment of patient safety status in OR, the identification of hazards, and the assessment of risks that jeopardize this safety. This is a descriptive observational study carried out in three ORs of a governmental hospital. The study was carried out from December 2008 through April 2009. A total of 100 patients undergoing general surgical and urological surgical procedures were selected. The data collection tools included the WHO surgical safety checklist, nonstructured interviews, patient records, anesthesia checklist, and the risk assessment matrix. According to the WHO safety checklist, patients' safety was checked during three stages. During the 'sign in' stage, only 3% of all the patients had the operation site marked for surgery and an incident of a single wrong side surgery was recorded. There was a clear lack of communication between doctors and patients. During the 'time out' stage, 80% of surgeries lacked organized discussion among surgical team members for anticipated critical events. Prophylactic antibiotics were administered to 59% of patients undergoing surgeries. The 'sign out' stage was properly carried out in 100% of the procedures. Risk assessment in the 'sign in' stage showed six of 11 procedures leading to a major risk to patients. Also, in the 'time out' stage, three of eight procedures had a major risk. To reach an optimal level of patient safety in the OR, it is recommended that the checklist should be implemented as part of the daily surgical routine. Identification of the hazards to which patients could be exposed and assessment of risks must be the ultimate goal in any OR.

Laterality Errors in Radiology Reports Generated With and Without Voice Recognition Software: Frequency and Clinical Significance

The aim of this study was to determine the incidence, types, and clinical implications of laterality errors and the effect of voice recognition software on the frequency of laterality errors. All radiology reports generated between January 2007 and April 2011 were retrospectively evaluated to identify revised reports containing laterality errors. Type of error was catalogued with regard to modality, body part, type of discrepancy (major or minor, with discrepancies considered major if the potential existed to affect patient management), duration of time between report finalization and corrected report, clinical significance, and use of voice recognition. The rate of errors causing major and minor discrepancies between voice recognition-generated reports and nonvoice recognition-generated reports was compared. Among 2,923,094 reports, 1,607 (0.055%) contained corrected laterality errors, and 56 (0.0019% of the total report volume) were major. A total of 584,878 (20%) were generated using voice recognition. The rate of laterality errors leading to major discrepancies in voice recognition-generated reports was 0.00188%, compared with 0.00192% in nonvoice recognition-generated reports (P = .9436). None of the errors led to wrong-sided surgery. However, there were potential adverse effects due to laterality errors in 3 patients with major discrepancies (0.000103% of the total report volume). Rates of laterality errors were low and, in our population, did not result in wrong-sided surgeries. Rates of laterality errors in reports with major discrepancies were unaffected by voice recognition software, but voice recognition was associated with a significant reduction in the duration of time between report finalization and the issuing of a corrected report.

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.

Developing an integrated clinical risk management model for Hospitals

Context: Improving patient safety in health systems is one of the main priorities in healthcare systems, for this reason clinical risk management in organizations has become increasingly significant. Although several tools have been developed for clinical risk management, each has its own limitations. Aims: This study aims to develop a comprehensive tool that can complete the limitations of each risk assessment and management tools with the advantage of other tools. Settings and Design: Procedure was determined in two main stages included development of an initial model during meetings with the professors and literature review, then implementation and verification of final model. Subjects and Methods: This study is a quantitative − qualitative research. In terms of qualitative dimension, method of focus groups with inductive approach is used. To evaluate the results of the qualitative study, quantitative assessment of the two parts of the fourth phase and seven phases of the research was conducted. Purposive and stratification sampling of various responsible teams for the selected process was conducted in the operating room. Final model verified in eight phases through application of activity breakdown structure, failure mode and effects analysis (FMEA), healthcare risk priority number (RPN), root cause analysis (RCA), FT, and Eindhoven Classification model (ECM) tools. This model has been conducted typically on patients admitted in a day-clinic ward of a public hospital for surgery in October 2012 to June. Statistical Analysis Used: Qualitative data analysis was done through content analysis and quantitative analysis done through checklist and edited RPN tables. Results: After verification the final model in eight-step, patient's admission process for surgery was developed by focus discussion group (FDG) members in five main phases. Then with adopted methodology of FMEA, 85 failure modes along with its causes, effects, and preventive capabilities was set in the tables. Developed tables to calculate RPN index contain three criteria for severity, two criteria for probability, and two criteria for preventability. Tree failure modes were above determined significant risk limitation (RPN > 250). After a 3-month period, patient's misidentification incidents were the most frequent reported events. Each RPN criterion of misidentification events compared and found that various RPN number for tree misidentification reported events could be determine against predicted score in previous phase. Identified root causes through fault tree categorized with ECM. Wrong side surgery event was selected by focus discussion group to purpose improvement action. The most important causes were lack of planning for number and priority of surgical procedures. After prioritization of the suggested interventions, computerized registration system in health information system (HIS) was adopted to prepare the action plan in the final phase. Conclusion: Complexity of health care industry requires risk managers to have a multifaceted vision. Therefore, applying only one of retrospective or prospective tools for risk management does not work and each organization must provide conditions for potential application of these methods in its organization. The results of this study showed that the integrated clinical risk management model can be used in hospitals as an efficient tool in order to improve clinical governance.

Incidence of Neurosurgical Wrong-Site Surgery Before and After Implementation of the Universal Protocol

Although exceedingly rare, wrong-site surgery (WSS) remains a persistent problem in the United States. The incidence is thought to be 2 to 3 per 10 000 craniotomies and about 6 to 14 per 10 000 spine surgeries. In July 2004, the Joint Commission mandated the Universal Protocol (UP) for all accredited hospitals. To assess the effect of UP implementation on the incidence of neurosurgical WSS at the University of Illinois College of Medicine at Peoria/Illinois Neurological Institute. The Morbidity and Mortality Database in the Department of Neurosurgery was reviewed to identify all recorded cases of WSS since 1999. This was compared with the total operative load (excluding endovascular procedures) of all attending neurosurgeons to determine the incidence of overall WSS. A comparison was then made between the incidences before and after UP implementation. Fifteen WSS events were found with an overall incidence of 0.07% and Poisson 95% confidence interval of 8.4 to 25. All but one of these were wrong-level spine surgeries (14/15). There was only 1 recorded case of wrong-side surgery and this occurred after implementation of the UP. A statistically greater number of WSS events occurred before (n = 12) in comparison with after (n = 3) UP implementation (P < .001). A statistically significant reduction in overall WSS was seen after implementation of the UP. This reduction can be attributed to less frequent wrong-level spine surgery. There was no case of wrong procedure or patient surgery and the 1 case of wrong-side surgery occurred after UP implementation.

Wall Building

Wall Building

Prevention of Wrong Site Surgery During Upper Tract Endoscopy

To evaluate the use of radiopaque stickers during endoscopic surgical cases to prevent wrong side surgery. We used radiopaque markers before planned endoscopic surgery to ensure correct side surgery. These markers are labeled "R" and "L" and are identifiable during fluoroscopy. These markers were a valuable tool to prevent wrong side endoscopic upper tract procedures. They were also well-accepted by patients at their preoperative surgical verification process. Radiopaque stickers can assist in the prevention of wrong side surgery during upper tract endoscopic procedures.

Canadian Chief Executive Officers' Prescription for Higher Quality: More Clinical Engagement, Shared Accountability and Capacity Development

uality of Healthcare in Canada: A Chartbook, published by the Canadian Health Services Research Foundation (CHSRF) in 2010, showed that when compared with other developed countries, Canada ranks in the middle of the pack with respect to healthcare quality. How we can best achieve higher-quality care is a much-debated issue in Canada and in most modern healthcare systems – and there are many conflicting views. The historical guild of professionalism through selfregulating professional colleges remains intact, especially for issues of poor conduct or criminal behaviour. However, there is widespread evidence of errors of commission (e.g., wrong-sided surgery or medication error) and omission (e.g., under-managed care or infection caused by an absence of hand hygiene) and unacceptable variation in quality of care (CHSRF 2011). So beyond the regulatory bodies, important new organizational, managerial and legislative imperatives are emerging to improve quality. With the emergence of “accountable care organizations” in the United States and new legislation in several Canadian provinces promising greater attention to performance measurement and reporting, there is increasing movement toward enhancing accountability structures and mechanisms as a means of achieving higher-quality care. To promote further examination of accountability for quality, CHSRF, in partnership with the Association of Canadian Academic Healthcare Organizations, the Canadian Institute for Health Information and the Canadian Medical Association, chose Leadership Accountability in Canadian Healthcare: Creating the Momentum to Improve Quality as the theme of the fifth annual CEO Forum in Montreal on February 16, 2011. Over 150 leaders from various sectors of Canada’s healthcare system were in attendance at the forum. As part of the program, a polling exercise was conducted to gain participants’ perspectives on quality and to promote discussion.

Wrong‐side/site surgery

AbstractWith the recent increased focus on patient safety, various measures have been put in place to make it very difficult to perform wrong‐site or wrong‐side surgery. Copyright © 2011 Wiley Interface Ltd

Henna as a Durable Preoperative Skin Marker

For many surgical procedures skin marking is required well before surgery and induction of anesthesia. In some cases, the patient may need to be standing or sitting while the skin area is marked. Marking of perforators and varicosities in chronic venous diseases, marking of stoma sites for urinary or fecal diversions are some examples. The side of surgery should ideally be marked preoperatively to avoid wrong side surgery. Marks made with conventional marking pens fade or disappear with preoperative skin preparation, whereas marks made with henna paste, which is orange to dark brown in color, last for up to 3weeks in spite of regular showers and skin cleansing, even with ethanol. This property of henna encouraged us to use it as a preoperative skin marker. Henna paste was used as a preoperative skin marker in 250 patients. In 154 patients with chronic venous diseases, perforators and varicosities were marked during duplex scanning. Henna was used to mark the colostomy site in 28 patients with carcinoma of the rectum prior to abdominoperineal resection of the rectum (APR) (four of them laparoscopic APR) and the aspiration site in 11 patients with liver abscesses and 4 patients with pleural empyemas, under ultrasonographic (USG) guidance. In addition, henna was used to mark the correct side of surgery in 47 patients undergoing unilateral inguinal hernia surgery. Marking was done from 1 to 8days before surgery. The marking with henna was clearly visible in all the cases even after preoperative skin preparation with ethanol up to 8days after application. There were no complications associated with the marking. All marks disappeared 4weeks after application. In terms of successful execution of the desired procedure, the use of henna marking was successful in all the cases. Henna is an ideal substance for use as a preoperative skin marker. It can be safely and effectively used as a marker for varicose vein surgery, ultrasound-guided identification of lesions, establishing the ideal site for stomas on the abdominal wall, and to identify the correct side of surgery. Markings made with henna are durable and do not fade with routine bathing or preoperative skin preparation. In most cases there are no associated complications. Henna is cheap, safe, and convenient, and indications for its use can be ubiquitous.

Wrong-site sinus surgery in otolaryngology

Objective To determine the scope of wrong-site sinus surgery. Study Design Electronic mail survey. Setting E-mailed via the American Academy of Otolaryngology–Head and Neck Surgery's weekly newsletter. Subjects and Methods Members were asked about wrong-site sinus surgery in an 11-item survey. Results A total of 455 members responded (response rate 19.8%). Forty-two (9.3%) have heard of a case of wrong-site sinus surgery occurring. Twenty-one cases were analyzed; of these, 10 (48%) implicated radiographic error, and the Universal Protocol was followed in one third. In seventeen reports (81%), there was disclosure to the family, one case with delayed disclosure; there was no disclosure in three cases. Sixty-one percent (n = 266) are concerned about operating on the wrong sinus or side. Forty-nine percent (n = 216) routinely use a checklist preoperatively. There is large variation in site marking for sinus surgery. Sixty-five percent (n = 282) routinely review the computed tomography scan prior to surgery. Conclusion Approximately 10 percent of survey respondents know of a case of wrong-site sinus surgery occurring; the majority of respondents are concerned about a wrong-sinus or wrong-sided surgery occurring in their practice. Otolaryngologists should be vigilant regarding the potential for inverted computed tomography images; there should be national efforts to address this latent systems defect. Surgeons should be trained in understanding the role of and engaging in disclosure and in other techniques that are of greatest support to the patient. Consideration of sinus-specific checklists should be led by the societies representing sinus surgeons.

138. Rates of Infection Following Spine Surgery Based on 108,419 Procedures: A Report from The Scoliosis Research Society Morbidity and Mortality Committee

BACKGROUND CONTEXT: The Centers for Medicare and Medicaid Services (CMS) has created a list of “never events” and proposed denial of hospital payment for their treatment. While some of these are preventable, including wrong side surgery, wound infection following spine surgery, which is also listed as a “never event”, is multifactorial and occurs despite meticulous efforts.

Importance of side marking in ophthalmic surgery

In 2003 the National Patient Safety Agency (NPSA) advised side marking for avoiding errors and reducing incorrect side surgery. This survey aimed to ascertain whether or not, these 'best practice' guidelines are currently being implemented by ophthalmic surgeons in Scotland and, if not, the reasons for this, and also to ascertain surgeons' attitudes towards marking. Semi-structured interviews with ophthalmic surgeons throughout Scotland, either face to face or by telephone, on their current practices and attitudes relating to preventing wrong side surgery. Non-compliance with side marking was described by 48% of the surgeons, which includes both consultants and specialist registrars. This survey reveals incomplete implementation of this policy in ophthalmic surgery for a number of reasons. The most common was bypassing the established multi-step process of checks, which risks an increased likelihood of surgical errors. Guidelines are not consistently being implemented in their entirety by eye surgeons in Scotland. In order to improve compliance and improve patient safety, we suggest a risk-stratified approach in side marking based on individual patient factors that may encourage wider acceptance, without compromising patient safety.

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,...

Wrong-Sided Surgery

Perhaps the single greatest error that a surgeon hopes to avoid is operating at the wrong site. In this report, the authors describe the incidence and possible determinants of incorrect-site surgery (ICSS) among neurosurgeons. The authors asked neurosurgeons to complete an anonymous survey. These surgeons were asked to report the number of craniotomies and lumbar and cervical discectomies performed during the previous year, as well as whether ICSS had occurred. They were also asked detailed questions regarding the potential determinants of ICSS. There was a 75% response rate and a 68% survey completion rate. Participating neurosurgeons performed 4695 lumbar and 2649 cervical discectomies, as well as 10,203 craniotomies. Based on this self-reporting, the incidence of wrong-level lumbar surgery was estimated to be 4.5 occurrences per 10,000 operations. The ICSSs per 10,000 cervical discectomies and craniotomies were 6.8 and 2.2, respectively. Neurosurgeons recognized fatigue, unusual time pressure, and emergent operations as factors contributing to ICSS. For spine surgery, in particular, unusual patient anatomy and a failure to verify the operative site by radiography were also commonly reported contributors. Neurosurgical ICSSs do occur, but are rare events. Although there are significant limitations to the survey-based methodology, the data suggest that the prevention of such errors will require neurosurgeons to recognize risk factors and increase the use of intraoperative imaging.

Wrong-Sided Surgery

Wrong-Sided Surgery

Wrong-Sided Surgery

Wrong-Sided Surgery

Getting surgery right.

We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part). We examined all reports from all hospitals and ambulatory surgical centers--in a state that requires reporting of wrong-site surgery--from the initiation of the reporting requirement in June 2004 through December 2006. Over 30 months, there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient (34), wrong procedure (39), wrong side (298), and/or wrong part (60); 83 patients had incorrect procedures done to completion. Procedures on the lower extremities were the most common (30%). Common contributions to errors resulting in the initiation of wrong-site surgery involved patient positioning (20) and anesthesia interventions (29) before any planned time-out process, not verifying consents (22) or site markings (16), and not doing a proper time-out process (17). Actions involving operating surgeons contributed to 92. Common sources of successful recovery to prevent wrong-site surgery were patients (57), circulating nurses (30), and verifying consents (43). Interestingly, 31 formal time-out processes were unsuccessful in preventing "wrong" surgery. Wrong-site surgery continues to occur regularly, especially wrong-side surgery, even with formal site verification. Many errors occur before the time-out; some persist despite the verification protocol. Patients and nurses are the surgeons' best allies. Verification, starting with verification of the consent, needs to occur at multiple points before the incision.

Achieving the National Quality Forum's “Never Events”

Review the evidence regarding methods to prevent wrong site operations and present a framework that healthcare organizations can use to evaluate whether they have reduced the probability of wrong site, wrong procedure, and wrong patient operations. Operations involving the wrong site, patient, and procedure continue despite national efforts by regulators and professional organizations. Little is known about effective policies to reduce these "never events," and healthcare professional's knowledge or appropriate use of these policies to mitigate events. A literature review of the evidence was performed using PubMed and Google; key words used were wrong site surgery, wrong side surgery, wrong patient surgery, and wrong procedure surgery. The framework to evaluate safety includes assessing if a behaviorally specific policy or procedure exists, whether staff knows about the policy, and whether the policy is being used appropriately. Higher-level policies or programs have been implemented by the American Academy of Orthopaedic Surgery, Joint Commission on Accreditation of Healthcare Organizations, Veteran's Health Administration, Canadian Orthopaedic, and the North American Spine Society Associations to reduce wrong site surgery. No scientific evidence is available to guide hospitals in evaluating whether they have an effective policy, and whether staff know of the policy and appropriately use the policy to prevent "never events." There is limited evidence of behavioral interventions to reduce wrong site, patient, and surgical procedures. We have outlined a framework of measures that healthcare organizations can use to start evaluating whether they have reduced adverse events in operations.

An observational study of laterality errors in a sample of clinical records

Confusing left with right eyes can have a potentially serious adverse outcome. The most extreme occurrence is wrong site surgery but even potentially less serious errors can undermine patient confidence in their medical care. This study was designed to look into how often this could be detected in clinical notes. An observational study conducted in an ophthalmic hospital. Hundred patients were randomly selected and their clinical notes retrieved. Notes were analysed for the number of left/right transpositions, which part of the notes they were found and whether they were corrected. Forty-four transposition errors were found in 32 sets on notes. The commonest error was drawing the eye on the wrong side of the page. The commonest place where errors were found was in the written outpatient notes. Nineteen of the errors had evidence of later correction. Three consent forms had the incorrect eye denoted and one patient was listed for surgery on the wrong side although this error was corrected before the operation. As far as we are aware, this study is the first to look at how often, in standard clinical notes, left/right transposition occurs. Although a direct link cannot made between their occurrence and later wrong side surgery, intuitively it would be reasonable to think it could increase the likelihood if other defences were to fail. We make a number of recommendations that might reduce this confusion and therefore more serious consequences.