Every other day a wrong-site surgery or a near miss occurs in the State of Pennsylvania. These are the findings of the state’s Patient Safety Authority released in a safety advisory published in 2007. In the 30-month investigation period, the Authority received reports of 427 near misses and serious events of wrong-site surgery. Of those, 253 were near misses or were discovered before they reached the patient.
“Wrong-site surgeries in Pennsylvania should never occur,” said Dr. Stan Smullens who is vice-president of the Patient Safety Authority Board of Directors. “However, every other day in Pennsylvania we have a report of a wrong-site surgery being caught either before or after the start of an operation.”
The causes of these problems are multiple, according to the Authority, including the following: multiple procedures and/or multiple surgeries being performed; communication breakdowns; time pressures; incomplete preoperative assessments; and organizational cultural factors that are not conducive to promoting teamwork, such as an attitude that a surgeon’s decisions should never be questioned.
Dr. Smullens went on to further comment on the types of errors involved. “Of those events that reached the patient in the operating room, 69 percent were wrong side surgeries, 14 percent were wrong body part surgeries, 9 percent were wrong procedure and 8 percent were wrong patient.” The extremities of the body, the eyes and the spine were the areas of the patient’s body where the errors most frequently occurred. Orthopedic and ophthalmologic procedures were the most common for wrong-site surgeries.
And, how does the state of Pennsylvania compare to the rest of the nation in reporting this apparent high level of medical error? “Wrong-site surgeries are no more common in Pennsylvania than they are in other states,” said Dr. Smullens. “We also have in common with other states the problem of trying to fix them.”
Some protocols have been established in the state in an attempt to reduce the problem. Basically, it starts with a commitment in each hospital and hospital organization’s leadership to fully attend to patient safety. Some simple reminders as posters and special stickers are placed in hospitals to promote a “time out” before a surgery starts. This is done to be certain that the procedure is being performed correctly and that it is being done on the right patient.
Additionally, patients and family members are an important component in making certain that procedures are correct. “We’ve 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,” said Dr. Smullens.