Wrong-site Surgery Research Articles

How We Do It: An Illustrative Biopsy Protocol for Preventing Wrong-Site Surgery.

How We Do It: An Illustrative Biopsy Protocol for Preventing Wrong-Site Surgery.

WP8.2 - Human Factors Analysis of CORESS cases using the NOTSS Framework

Abstract Aims Determine human factors implicated in cases submitted to the Confidential Reporting System in Surgery (CORESS), using the non-technical skills for surgeons (NOTSS) framework. Methods Consecutive cases submitted to CORESS, between 2005 and 2011 were evaluated as an interim analysis. The type of case, whether patient harm occurred, Clavien-Dindo (CD) classification, and the location of the incident were collected. Demographic data was not collected because they are often changed to protect patient identification. Each case was reviewed according to the non-technical skills for surgeons (NOTSS) taxonomy. Results There were 100 cases included in this interim analysis. The most common types of cases were delayed diagnosis (n=19), known complications (n=10), near misses (n=10), poor surgical technique (n=9), misuse of equipment/device (n=8), and wrong site surgery (n=5). Two-thirds of patients were harmed, with complications ranging from minor to life-threatening (9 CD I, 10 CD II, 32 CD III, 12 CD IV), and 4 resulting in death (CD V). Incidents occurred most frequently in the operating theatre (n=54), the ward (n=16), or the emergency department (n=9). There were 71 incidents that endangered patient safety related to deficiencies in situational awareness, 59 to poor communication and teamwork, 48 to poor decision-making, and 48 related to leadership failures. Conclusions The main human factors implicated in surgical patient safety incidents related to errors in situational awareness, communication and teamwork, and to a lesser extent, decision-making, and leadership. Efforts to prevent medical errors should be focused on clinician human factors training.

P97. Reducing wrong-site spine surgeries: an update of a single tertiary institution's iterative policy

P97. Reducing wrong-site spine surgeries: an update of a single tertiary institution's iterative policy

Risk Factors for Wrong-Site Surgery: A Study of 1,166 Reports of Informed Consent and Schedule Errors

Background The accuracy of informed consent and procedural schedule are important components in a process for preventing wrong-site surgery. Methods In our study of a four-year period, we used the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to explore the occurrence of consent and/or schedule errors at all licensed hospitals and ambulatory surgical facilities (ASFs) in Pennsylvania. We also evaluated the reports for consent and schedule error subtypes: side, procedure, site, and patient. Results Over a four-year period, 1,166 event reports described a consent and/or schedule error, and 86% of the reports were from hospitals and 14% were from ASFs. Among the 1,166 reports, 56% described a schedule error, 34% had a consent error, and 10% involved both error types. In the sample of reports, the frequency of error subtypes were ranked in the following sequence: side (69%), procedure (24%), site (4%), and patient (3%). The analysis also revealed similarities and differences in the distribution of error types and subtypes across hospitals and ASFs. Conclusions Based on the results, it is evident that consent and schedule errors are issues across many healthcare facilities. The findings by error subtype (side, procedure, site, patient) show some similarity in distribution with previous studies of wrong-site surgery events. We recommend that readers review Table 4 and Table 5 for a brief literature review of risk factors for consent and schedule errors and strategies for preventing and detecting the occurrence of those errors, respectively.

Enhancing Clarity and Patient Safety: Evaluating the Inclusion of Laterality in Orthopaedic Outpatient Correspondence in Galway, Ireland.

Background In medical documentation, accurate mention of laterality, whether a condition or treatment pertains to the left or the right side of the body, is critical for avoiding errors like wrong-site surgeries, which can have severe repercussions. This study aims to assess compliance regarding the mention of laterality in outpatient clinic letters at Galway University Hospital. Methods An analytical cross-sectional study was conducted at Galway University Hospital from February to August. We reviewed outpatient letters in the Orthopaedic Department. The Fisher exact and Chi-square tests were employed to observe the association between the levels of practitioners and laterality. Results A total of 278 outpatient letters from 37 practitioners in one week were analyzed. The overall laterality rate was 65.1%.It was observed that there was a male predominance in the workforce (31; 83.8%). Conclusion In conclusion, our study revealed satisfactory improvement in the prevalence of mentioning laterality among healthcare providers. It is recommended that educational sessions and re-auditing be carried out to enhance the quality of care.

PENGISIAN SIGN IN DALAM MENINGKATKAN KEPATUHAN SAFE SURGERY DI RUMAH SAKIT PKU MUHAMMADIYAH YOGYAKARTA II

Background: Complications and deaths due to surgery become one of the global health problems. World Health Organization estimates that at least half a million deaths due to preventable surgical. An effort to improve the quality of surgical services including the Surgical Safety Checklist to use made by World Health Organization. Compliance to use this surgery checklist which is can increase the number of safe surgery,reduce the wrong site surgery and nearmiss.
 Method: This research is a qualitative action research design. The study population was all the doctors and nurse anesthetist. Number of samples 6 people. The data is collected by observation sheet Surgical Safety Checklist: Sign In RS PKU Muhammadiyah Yogyakarta Unit II for 3 cycles of observation.
 Result and Discussion: The results of observations on the first to the third cycle shows that all disobeying nurse anesthetist (100%) the Surgical Safety Checklist to fill: Sign In. The results of the response every cycle and a structured interview with the anesthesiologist showed that nurses are still confused how to use the checklist, the checklist has not been a necessity, the culture of patient safety is still minimal, lack quality of human resources, lack of supervision and lack of socialization mechanisms Surgical Safety Checklist noncompliance that influence nurses Sign In to to fill.
 Conclusion: Completing Sign In in the installation of surgery center in PKU Muhammadiyah Yogyakarta Unit II Hospital is noncompliance, because they still haven’t got the identity bracelet mounted on a patient who will be operating and marking the location of a rare surgery. Advice to hospital are to create a Standard Operating Procedure (SOP), SOP socialize regularly, make in-house training, increase the commitment of doctors and nurses, create a surveillance system, create a system of reward and punishment.

Circumferential digit marking to prevent inadvertent wrong site surgery or anesthetic administration

Circumferential digit marking to prevent inadvertent wrong site surgery or anesthetic administration

Urology never events in the United Kingdom: A retrospective 10‐year review

AbstractObjectivesThe aim was to assess the prevalence of never events (NEs) specific to urology in the United Kingdom and identify commonly occurring themes.MethodsData from the National Health Service (NHS) NEs website were obtained and all NEs from 2012 to 2022 were reviewed. Urology‐specific NEs were identified and further analysed in their respective categories. Data regarding the total number of surgical procedures performed in the NHS specific to each specialty were obtained via the NHS Hospital Episode Statistics website.ResultsThere were 3972 NEs recorded over the 10‐year period with 95 (2.4%) of these as a result of urology surgery. The most common surgical intervention associated with a urological NE was ureteric stenting, which comprised 45/95 (47.4%) of all analysed NEs. These consisted of wrong site ureteric stent insertion (n = 29), wrong site ureteric stent removal (n = 9), wrong stent type (n = 5) and retained guidewires (n = 2). There were 7.14 million urology surgeries performed in the 10‐year period, and prevalence was 0.0013%.ConclusionNEs are fully preventable serious incidents in the NHS. This is the first study to investigate the prevalence of NEs in urology in the United Kingdom. This study demonstrates that in the last 10 years the prevalence of urology NEs is low at 0.0013%, with ureteric stent procedures accounting for more than half of the NEs. Urologists should be mindful of the potential for wrong site surgery in urologic stenting procedures.

The Effect of Pre-Anesthesia Assessment on Patient Safety in the Operating Room

Background: The development of the science of anesthesia provides consideration in administering the type of anesthesia used. The pre-anesthesia assessment is the basis for planning the findings on the monitor during and after anesthesia. The completeness of the pre-anesthesia assessment has an important role in patient safety, if the anesthetic assessment is not properly completed it allows errors in the operation process. Patient safety goals are the main requirement to be implemented in all hospitals accredited by KARS. Patient safety goals intend to drive specific improvements in patient safety. This goal highlights problematic areas of health care. The wrong-site, wrong procedure and wrong-patient surgery are something that is worrying and not uncommon in the hospital. This error resulted from ineffective communication between members of the surgical team, not involving the patient in site marking, and no procedure for verifying the surgical site. Objective: The study aims to see the effect of the completeness of the pre-anesthesia assessment on patient safety. Methods: The research design is a cross-sectional study. The population in this study were patients who underwent surgery with a total sample of 70 people. Data processing through the stages of editing, coding, entry, and cleaning. Univariate analysis and bivariate analysis used the chi-square test with a 95% degree of confidence α = 0.05. Results: The results showed that the completeness of the pre-anesthesia assessment was complete with a percentage of 88.6%. Good patient safety with a percentage of 65.7%. There was no significant relationship between the completeness of the pre-anesthesia assessment and patient safety (p=0.076). Conclusions: To improve the implementation of pre-anesthesia assessments, hospitals need to review the completeness of filling out pre-anesthesia assessments by anesthesiologists before patients are operated on, to prevent errors in improving patient safety. Prepare facilities and infrastructure for the needs of patient safety programs by accreditation standards.

Enhanced Recovery After Surgery (ERAS) Spine Pathways and the Role of Perioperative Checklists.

Enhanced recovery after surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. ERAS pathways have been shown to help reduce complications, hospital length of stay (LOS), 30-day readmission rates, pain scores, and ultimately surgical costs, while improving patient satisfaction scores and outcomes in multiple surgical subspecialties [1-6]. Numerous specialties have implemented ERAS programs across the globe, providing a foundation for spine surgeons to begin the process themselves. Over the last few years, a significant number of papers have been addressing ERAS pathways for spinal surgery [7-19]. The majority have addressed the lumbar spine [9, 20-26]. The number of cervical ERAS pathways has been limited [27-29]. Many spine programs have begun the implementation of ERAS pathways, incorporating principles and interventions to various spine surgical procedures. Although differences in implementation across programs exist, there are a few common elements that promote a successful enhanced recovery approach [11, 16, 23, 25, 30-33]. All spinal ERAS pathways have three major elements, which are preoperative, perioperative, and postoperative phases. Within these phases some common elements include preoperative and intraoperative surgical checklists. Intraoperative checklist in addition to the "surgical time out" has been integrated into the workflow of most hospitals doing surgeries and have become a standard of care. The surgical checklist is designed to help reduce surgical errors and prevent wrong site/patient surgeries. Several surgical checklists have been developed throughout the years. Despite these safety protocols wrong site/level and other surgical errors continue to occur. Many cases of wrong level spine surgery (WLSS) still occur even when intraoperative imaging is performed [34, 35]. One survey reported that about 50% of spine surgeons have performed at least one WLSS during their career [36, 37]. Another survey reported that 36% of spine surgeons had performed at least one WLSS that was not recognized intraoperatively [38]. On a similar account, about 30% of spine surgery fellows have experienced wrong-site surgery [39]. From raw incidence rates, WLSS may seem rare, but these surveys show that the experience of WLSS is rather common among spine surgeons. WLSS is not yet a "never event." This may be due to poor quality of the intraoperative images, hindering subsequent level identification [34, 35, 38, 40]. Errors in interpretation of the imaging may also occur, including inconsistency in numbering vertebrae, inconsistency in landmark usage for level counting, and problems with numbering vertebrae due to lumbosacral transitional vertebrae (LSTV) and other anatomical variants [34, 38, 41-43]. This chapter will describe a framework for the development and implementation of ERAS pathway for patients undergoing spine surgery. In addition, we will propose preoperative imaging guidelines and a comprehensive spine surgical checklist to incorporate into the perioperative phase to help reduce further surgical errors and WLSS.

Increase Noted in Reported Wrong-Site Surgery Events From Interventional Radiology

Increase Noted in Reported Wrong-Site Surgery Events From Interventional Radiology

A five-step approach to safer skin surgery

Background: Wrong site skin surgery is a never event with implications for patient well-being, in addition to potential medicolegal ramifications. There is no standardised approach to wrong site surgery (WSS) prevention in the United Kingdom. However, the World Health Organisation surgical checklist and NHS England's safety standards for invasive procedures (NatSSIP) have been useful in guiding the direction of change. Our experience: We describe our experience over the past decade, detailing five cases of WSS including three wrong site biopsies and two re-excisions of the wrong scar. Each provided a learning opportunity, identifying vulnerabilities in the skin surgery pathway. Our five-step approach to safer skin surgery: By reflecting on our experience, we created a simple five-step approach to safer skin surgery which could easily be adopted by other dermatology departments. This includes, developing a Standard operating procedure, requesting a surgical procedure, medical photography, in theatre, and education/governance. Our approach provides a step in the right direction for national standardisation of the skin surgery pathway.

Artificial Intelligence Image Recognition System for Preventing Wrong-Site Upper Limb Surgery.

Our image recognition system employs a deep learning model to differentiate between the left and right upper limbs in images, allowing doctors to determine the correct surgical position. From the experimental results, it was found that the precision rate and the recall rate of the intelligent image recognition system for preventing wrong-site upper limb surgery proposed in this paper could reach 98% and 93%, respectively. The results proved that our Artificial Intelligence Image Recognition System (AIIRS) could indeed assist orthopedic surgeons in preventing the occurrence of wrong-site left and right upper limb surgery. At the same time, in future, we will apply for an IRB based on our prototype experimental results and we will conduct the second phase of human trials. The results of this research paper are of great benefit and research value to upper limb orthopedic surgery.

The Effects of a Simulation-Based Patient Safety Education Program on Compliance with Patient Safety, Perception of Patient Safety Culture, and Educational Satisfaction of Operating Room Nurses.

Operating rooms (ORs) are healthcare areas that are high-risk regarding patient safety (PS). The prevention of PS errors such as wrong-site surgery, medication errors, and patient falls is important in the OR. Causes such as having insufficient information, not taking enough care and precautions, and inattention may lead to errors. Ensuring PS in an organization depends on the composition of a PS culture. This study, as equivalent-control-group pretest-posttest research, aimed to develop and apply a simulation-based patient safety education program for operating room nurses and then to examine the influence of the program on patient safety management and compliance. Participants included a total of 45 operating room nurses: 22 in the experimental group and 23 in the control group. In the program, each member of the experimental and control groups underwent two 60 min sessions for a total of 120 min. Person-to-person individual lectures and simulation-based practice were provided to the experimental group, whereas booklets and person-to-person individual lectures were provided to the control group. Compliance with patient safety, the perception of patient safety culture, and satisfaction were measured using a structured Likert questionnaire. Intervention effects were analyzed using a t-test and ANCOVA. As a result of the analysis, we found that the experimental group was significantly higher in terms of compliance with patient safety (p = 0.021), the perception of patient safety culture (p = 0.039), and education satisfaction (p < 0.001) than the control group. The results indicate that implementing a simulation-based patient safety education program can improve the patient safety competency of operating room nurses and, ultimately, prevent patient safety accidents in the operating room.

Common preventable errors in hand surgery: Analysis of NHS never events data and a proposed safety checklist.

Hand surgical procedures are common interventions in elective and emergency settings. The complex nature of the injuries and management by multiple specialities could be a potential source of medical errors and never events (NEs). Awareness of the common NEs could potentially help prevent their occurrence in the future. To analyse the NHS England database to identify the common NEs in hand surgery and present a simple, practical safety checklist for hand surgery. The NHS NEs database from 2012 to 2021 has been analysed to identify the common hand surgery-related never events. We identified the common categories and themes within. Our theme development process is based on anatomical considerations and the nature of the incidents. Additionally, we designed a simple Safety Checklist for hand surgery. We identified a total of 3742 never events with 50 incidents related to hand surgery, representing (1.3%). Wrong-site surgery was the commonest category (n =30), representing 60% of the hand surgery-related NEs. We identified seven different themes under wrong-site surgery. Wrong finger or digit surgery was the commonest theme, with 17 reported incidents representing 57% of wrong-site surgeries. This is followed by five wrong digits injections and three wrong k wire placements representing 16.6% and 10%, respectively. The second most common category was wrong incisions (n =15), representing 30%; 13 patients had wrong finger incisions. Two patients had carpal tunnel incisions before surgeons realised that the procedures were for trigger finger release.The third category included four wrong procedures, with two incidents of carpal tunnel release instead of trigger finger operation or Dequervain tendon release. Finally, one patient had an injection for carpal tunnel intended for another patient. Hand surgery-related NEs represent a small fraction (1.3%) of all NEs within the NHS database. We identified 50 hand surgery-related NEs arranged into 14 different themes. Additionally, we proposed a hand surgery-specific safety checklist to reduce the incidence of these incidents in the future.

WTP6.8 A Decade of NHS Never Events – Has formal reporting made a difference?

Abstract Introduction NHS England defines “Never Events” (NE) as 'patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers'. NHS Organisations were required to publish data on NE from April 2012. This project aims to identify changes in NE patterns to help inform future learning. Methods All published data between April 2012 and March 2022 was collected from NHS England. Data processing and manipulation was carried out using Microsoft Excel. Results A total of n=4,055 NE and n=175,920,530 procedures were reported. During the 2020-2021 year there were significantly less (p=0.029) NE compared to 2019-2020, however the rate of NE per million procedures (25 vs 27) remained unchanged p=0.18. Overall, there appears to be an increasing trend in NE, p&amp;lt;0.001. The majority of NE related to wrong site surgery, n=1,628(40%), retained foreign objects, n=1,090(27%) and wrong implant/prosthesis, n=506(12%), p&amp;lt;0.001. Within wrong site surgery, the most common NE was wrong procedure, n=529(32%), followed by laterality errors, n=391(24%), p&amp;lt;0.001. Discussion &amp; Conclusion The results demonstrate that despite systemic protective barriers such as the WHO Checklist, overall rate of NE has not reduced. This is likely to be confounded by changes in reporting as well as definitions, for example from April 2021 wrong tooth extraction was not considered a NE. The importance of Human Factors must not be overlooked, and NHS Trusts should consider formal provision of such training for all those in clinical roles.

Evaluating similarity measure for multimodal 3D to 2D registration

The 3D to 2D registration technique in spine surgery is vital to aid surgeons in avoiding the wrong site surgery by estimating the vertebral pose. The vertebral poses are estimated by generating the spatial correspondence relationship between pre-operative MR with intra-operative x-ray images, then evaluated using a similarity measure. Different similarity measures are used in 3D to 2D registration techniques to assess the spatial correspondence between the pre-operative and intra-operative images. However, to evaluate the registration performance of the similarity measures, the proposed framework employs three different similarity measures: Binary Image Matching, Dice Coefficients, and Normalized Cross-correlation technique to compare the images based on pixel positions. The registration accuracy of the proposed similarity measures is compared based on the mean Target Registration Error, mean Iteration Times, and success rate. In the absence of simulated test images, the experiment is conducted on the simulated AP and Lateral test images. The experiment conducted on the simulated test images shows that all three similarity measures work well for the feature based 3D to 2D registration in that BIM gives better results. The experiment also indicates high registration accuracy when the initial displacements are varied up to ±20 mm and ±100 of the translational and rotational parameters, respectively, for three similarity measures.

Surgical Safety Audit in India, or Lack Thereof: An Urgent Need for National Policy on Wrong-Site Surgery Registry and Research

Multiple studies have analysed the incidence of wrong-site surgeries (WSSs) in developed countries. This study aims to find out information relevant to the incidence and pattern of WSS in India. Multiple sources like Medline, EMBASE and the Global Health Library databases were searched for abstracts and citations in all languages published between 1 January 1975 and 31 December 2018, describing any WSS from India. After extensively searching the online databases only one case report related to WSS in India could be found. Zero incidences of WSS in general surgery from India seem fallacious and it is due to non-reporting of such events and the Government of India should implement a national registry to maintain data on WSS, which can lead to improved surgical care.

Wrong-Site Surgery in Spain and Professional Liability Claims.

Wrong-Site Surgery in Spain and Professional Liability Claims.

Surgical Marking Pen Contamination: Writing a Postoperative Infection Into Your Preoperative Plan.

Introduction Preoperative marking is an essential safety practice to prevent "never" events, including wrong site surgery. Moreover, the Joint Commission regulations of the Universal Protocol require that patients be marked to indicate the operative site. Marking typically occurs with a pen or marker, which may be disposable or reusable. Previous studies have demonstrated that methicillin-resistant Staphylococcus aureus (MRSA) can survive in the dark, moist, capped environment of the marking pen and thus could plausibly be a nidus for transmission from patient to patient. The Joint Commission has established no increased risk of postoperative infection with these markings. With this study, we aimed to determine the colonization of surgical marking pens in the plastic surgery population. Methods Two marking pens from five different attending plastic surgeons at a single institution were cultured in standard fashion for aerobic and anaerobic growth. All pens were used repeatedly in office settings for performing patient markings. Those same ten marking pens were then used to mark incision sites on mock patients. Standard povidone-iodine prepping was then performed in a paint-only fashion over the skin markings, and cultures were again taken. A control group consisted of cultures from five sterile pens from the operating room. Each sterile pen was opened, uncapped, and then swabbed. All twenty-five cultures were analyzed in the hospital laboratory in a blinded fashion. Results The five control pens revealed no bacterial growth. Of the 10 direct pen cultures, two samples grew coagulase-negative staphylococci and one culture contained Pseudomonas aeruginosa. The 10-patient marked and prepped specimens showed eight negative cultures and two with coagulase-negative staphylococci. Although Pseudomonas was detected on standard pen culture, no pseudomonal growth was present in any of the samples after patient marking and prepping with povidone-iodine. Conclusions Our findings reaffirm that marking pens may be vehicles for bacterial transmission and expand upon previous studies by describing the presence of bacterial colonization on marking pens even after surgical site preparation with povidone-iodine.