Archives of Surgery: Incidence, Patterns, and Prevention of Wrong-Site Surgery
Posted by Clark Venable on 4/21/2006
Incidence, Patterns, and Prevention of Wrong-Site Surgery [free]
"Results Among 2 826 367 operations at insured institutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112 994 operations (95% confidence interval, 1 in 76 336 to 1 in 174 825). Medical records were available for review in 13 cases. Among reviewed claims, patient injury was permanent-significant in 1, temporary-major in 2, and temporary-minor or temporary-insignificant in 10. Under optimal conditions, the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol might have prevented 8 (62%) of 13 cases. Hospital protocol design varied significantly. The protocols mandated 2 to 4 personnel to perform 12 separate operative-site checks on average (range, 5-20). Five protocols required site marking in cases that involved nonmidline organs or structures; 6 required it in all cases."
The facilities I work at use 'Time Out' and are gradually standardizing on the use of the word 'yes' to mark the site (which I believe to be the best). Administrators tend to add things to the Time Out so they can say they did something about a problem. Our time outs now require confirmation of a negative pregnancy test before GYN surgery as well as 'Implants Available' for cases that will use implants; a list which will no doubt get longer as more errors occur.
The article contains this jewel from a well known author on errors in medicine--James Reason:
"First, written checklists, although designed for easy use, are prone to several types of error: skipped steps due to interruptions and distractions and stating that an item has been completed (checking the box) when in fact it has not. Second, redundant checks can achieve an exponential decrease in risk of error but only if each checkpoint is independent. Third, increasing the number of involved caregivers can foster routine violations because the multiple checks begin to seem like "busy work." Finally, efforts to keep up with the pace of patient flow may lead to viewing violations of protocol as acceptable or necessary. Simplification of protocols would improve adherence and efficiency and allow surgical teams to focus their limited time and energy on prevention of more common or harmful errors."
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