To be frank, wrong-site surgeries in Pennsylvania should never occur. However, every other day in
In a 30-month time period (June 2004 through December 2006) the Authority received 427 near misses and serious events of wrong-site surgeries. Of those, 253 were near misses or did not reach the patient.
Of those events that reached the patient in the operating room, sixty-nine percent were wrong side surgeries, fourteen percent were wrong body part surgeries, nine percent were wrong procedure and eight percent were wrong patient, added Smullens. The most common sites where the wrong-site occurred were extremities, eyes and spine. Orthopedic and ophthalmologic procedures were the most common for wrong-site surgeries.
Smullens added that risk factors for wrong-site surgery include: multiple procedure and/or multiple surgeons; communication breakdowns; time pressures; incomplete preoperative assessments; and organizational cultural factors that are not conducive to promoting teamwork such as an attitude that surgeons decisions should never be questioned. However, he added that in many reports the patient or family member was responsible for correcting information that prevented the wrong-site surgery from occurring. The Authority has provided a consumer tip sheet for patients and families made available on its Web site at www.psa.state.pa.us under Tips for Consumers.
We know that patients and family members have been important components in stopping wrong-site surgeries from happening, said Smullens. So, weve developed a consumer tip sheet that provides patients and family members with advice to ensure they participate in their healthcare and reduce the likelihood of a wrong-site surgery.
Furthering the preventive cause, Dr. Anthony Ardire, senior vice president of quality and patient safety at Lehigh Valley Health System, spoke about what his organization has done to reduce and eliminate wrong-site surgeries. Ardire listed several steps that contributed to the Lehigh Valley Health Systems success in reducing and eliminating wrong-site surgeries. One crucial step is the commitment from the organizations leadership to patient safety.
At Lehigh Valley we have full support from senior administrative and clinical leadership on patient safety issues, in particular, wrong-site surgery prevention, Ardire said. Wrong-site surgery events are thoroughly evaluated with a formal root-cause analysis and are reported regularly to our organizations performance committee and board of directors.
Other important steps include collaborations that involve strategically placed posters as visual reminders and special stickers that promote time-outs prior to surgery. A time-out is the last in a series of steps launched in July 2004 as part of the Joint Commissions Universal Protocol for Preventing Wrong-Site, Wrong Procedure and Wrong Person Surgery. The step requires that a time-out occur to verify correct patient, correct procedure and correct site before any surgery begins.
It surprised many that since the Joint Commission launched its Universal Protocol, there has been a sustained increase, not decrease, in the number of reported cases of wrong-site surgeries, added Ardire. While some of the rise may be due to increased reporting, the fact remains that the incidence and frequency of this problem is not decreasing.
Ardire said since the implementation 18 months ago of Lehigh Valley Hospitals wrong-site surgery and procedure protocols, they have eliminated all wrong-site surgery and wrong-site procedures. It does take diligence on everyones part to prevent wrong-site surgeries and procedures, Ardire said. We believe you cant rely solely on education. Visual reminders, tracking and investigation of all events and near misses and multi-disciplinary collaboration are required.
Michael Doering, interim executive director of the Patient Safety Authority, spoke about the Authoritys plans to reduce and eliminate wrong-site surgeries in
Lynn Gurski Leighton, vice president of professional and clinical services for the Hospital & Healthsystem Association of Pennsylvania (HAP), also participated at the press conference in support of the Authority and its patient safety initiatives to reduce wrong-site surgery. Carolyn F. Scanlon, president and chief executive officer of HAP, could not attend but gave the following statement: "Patient safety is an integral part of every hospital's missionpatient safety starts with leadership and is carried through to every person in the organization. Patient safety must be owned, valued, tested and constantly improved. As partners with the Patient Safety Authority, committed to ongoing education and collaboration to reduce medical errors and create environments for learning and improving care, we support the Authority's work on the issue of wrong-site surgery. While a rare event in healthcare, wrong site surgery has far-reaching consequences for patients and caregivers. The Patient Safety Advisory points to multiple risk factors and system breakdowns that can occur in the complex world of medicine. And from this information, hospitals and health systems will continue to improve their protocols and practices to ensure such devastating mistakes do not occur."
Source: Patient Safety Authority