Wrong-site Surgery Occurs Every Other Day in Pennsylvania
A wrong-site surgery or close call occurs every other day in Pennsylvania health care facilities, according to a report released June 26, 2007, by the Patient Safety Authority.
Articles on patient safety are published four times a year in the authority’s Patient Safety Advisory. The most important articles from each issue are included in Studies in Patient Safety, which is available on the Pennsylvania Medical Society website for CME.
Between June 2004 and December 2006, the authority received reports of 253 near misses and 174 wrong-site surgeries in the state. Of those surgeries, 69 percent were performed on the wrong side and 14 percent on the wrong body part, nine percent were the wrong procedure, and eight percent were on the wrong patient.
The most common sites were the extremities, eyes, and spine and the most common procedures were orthopedic and ophthalmologic.
The Joint Commission on Accreditation of Healthcare Organizations has developed a protocol for preventing wrong-site surgery. The protocol requires a pre-operative verification process to verify the correct patient, procedure and site; marking the operative site; and a time out immediately before the procedure.
Lehigh Valley Health System has eliminated wrong-site surgeries since implementing a protocol 18 months ago, according to the Patient Safety Authority. The protocol includes a commitment to patient safety and posters and stickers that promote time outs prior to surgery.
Patients and family members also play an important role in preventing wrong-site surgeries. A consumer tip sheet has been created detailing how patients and families can help prevent errors.
The authority plans to research wrong-site surgery protocols and make recommendations to the state’s health care facilities.
The authority published an update on wrong-site surgery in June 2008.
Last Updated: 8/1/2008