Patient Safety Authority Visits Facilities for Information on Wrong-Site Surgery

HARRISBURG, Pa. -- While reports of wrong-site surgeries in the Commonwealth of Pennsylvania have decreased during 2007, some facilities continue to report wrong-site surgeries that may have been prevented had they followed protocols implemented by other Pennsylvania facilities that have been successful in preventing wrong-site surgeries in their institutions, according to analysis published by the Patient Safety Authority in its December 2007 Patient Safety Advisory.

Since the Authority first published the frequency of wrong-site surgeries in Pennsylvania in its June 2007 Patient Safety Advisory, a more in-depth analysis of facilities was conducted that shows some facilities are doing the right things to prevent wrong-site surgery, while others still have system weaknesses that make wrong-site surgery a possibility.

The Authority visited six volunteer hospitals. Four of the hospitals had more than one report of a wrong-site surgery within a two-and-a-half year time period and two hospitals had no reports of a wrong-site surgery during the reporting period. The Authority's team consisting of the Pennsylvania Patient Safety Reporting System's clinical director and two nurse analysts spent one day at each of the six facilities with a confidentiality agreement consistent with Act 13.

"From our recent observations, wrong-site errors usually result from either misinformation prior to the patient getting into the operating room or misperceptions of hospital staff once the patient is in the operating room," Dr. John Clarke, clinical director of the Patient Safety Authority said. "Misperception can occur from confusion regarding right or left and the failure to question authority, among other reasons."

Clarke added that there were several variations among facilities about how they interpreted and implemented the Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Considerable differences also occurred in how information prior to surgery was verified, how surgical sites were marked, and how time outs were done, as well as in all other steps when taking the patient through the operating room.

"We noted that wrong-site surgery errors were associated with the failure to identify incorrect information in the documents related to surgery, such as the schedule, consent and patient's history and physical examination [H &P] before the operation," said Clarke. "Hospitals that check for errors at every opportunity have more success in preventing misinformation from reaching the operating room -- and the more independent the checks the better."

Clarke added that verification of the patient's information should be done with questions that require active answers, such as what arm are we operating on? as opposed to questions that require passive answers, such as we're operating on your left arm, right?

"Our observations led us to appreciate that the mark on the site to be operated on represents the patient's voice after he or she is sedated or anesthetized," Clarke said. "The mark should be made with the help of the patient or patient advocate and should be made before the patient is sedated."

Other observations in regard to the site marking include that the mark should be made accurately and in a way consistent with the facility's protocol; the mark should be consistent with all documents completed prior to surgery; the mark should be made by someone who knows about the procedure and hospital protocol; and the mark should not be made with an "X" or something else that can be easily misinterpreted.

Source: Patient Safety Authority