Patient safety with particular reference to wrong site surgery – a presidential commentary

2009 ◽  
Vol 23 (2) ◽  
pp. 109-110 ◽  
Author(s):  
P. T. van Hille
2019 ◽  
Vol 13 (1) ◽  
Author(s):  
Arinze Duke George Nwosu ◽  
Fidelis Anayo Onyekwulu ◽  
Elias Chikee Aniwada

Abstract Background Adverse healthcare events are major public health problem with the heaviest burden in the low and middle-income countries. Patient safety awareness among healthcare professionals is known to impact this outcome; thus we set out to appraise the patient safety awareness among surgeons in Enugu, Nigeria. Methods A multi-institutional cross-sectional survey was carried out among surgeons in Enugu, Nigeria and data obtained were analyzed using the statistical package for scientific solutions (SPSS) version 20 software. Results A total of 309 surgeons were surveyed. Majority of the surgeons (51.9%) had poor perception of patient safety issues. One hundred and twenty respondents (38.8%) have awareness of any institutional protocol for preventing wrong-site surgery while only 35 respondents (11.3%) regularly practiced an institutional protocol for preventing wrong-site surgery. The professional status of the surgeons and years in service showed significant association with perception of patient safety issues. Conclusion The patient safety awareness and practice among the surgeons in Enugu, Nigeria is apparently low and this was found to be influenced by the professional status and years in service of the surgeon.


2013 ◽  
Vol 2 (3) ◽  
pp. 26 ◽  
Author(s):  
John R. Clarke

The Pennsylvania Patient Safety Authority receives over 235,000 reports of medical error per year. Near miss and serious event reports of common and interesting problems are analysed to identify best practices for preventing harmful errors. Dissemination of this evidence-based information in the peer-reviewed Pennsylvania Patient Safety Advisory and presentations to medical staffs are not sufficient for adoption of best practices. Adoption of best practices has required working with institutions to identify local barriers to and incentives for adopting best practices and redesigning the delivery system to make desired behaviour easy and undesirable behaviour more difficult. Collaborations, where institutions can learn from the experiences of others, have show decreases in harmful events. The Pennsylvania Program to Prevent Wrong-Site Surgery is used as an example. Two collaborations to prevent wrong-site surgery have been completed, one with 30 institutions in eastern Pennsylvania and one with 19 in western Pennsylvania. The first collaboration achieved a 73% decrease in the rolling average of wrong-site events over 18 months. The second collaboration experienced no wrong-site operating room procedures over more than one year.


2015 ◽  
Vol 97 (8) ◽  
pp. 592-597 ◽  
Author(s):  
WD Harrison ◽  
B Narayan ◽  
AW Newton ◽  
JV Banks ◽  
G Cheung

Introduction This study reviews the litigation costs of avoidable errors in orthopaedic operating theatres (OOTs) in England and Wales from 1995 to 2010 using the National Health Service Litigation Authority Database. Materials and methods Litigation specifically against non-technical errors (NTEs) in OOTs and issues regarding obtaining adequate consent was identified and analysed for the year of incident, compensation fee, cost of legal defence, and likelihood of compensation. Results There were 550 claims relating to consent and NTEs in OOTs. Negligence was related to consent (n=126), wrong-site surgery (104), injuries in the OOT (54), foreign body left in situ (54), diathermy and skin-preparation burns (54), operator error (40), incorrect equipment (25), medication errors (15) and tourniquet injuries (10). Mean cost per claim was £40,322. Cumulative cost for all cases was £20 million. Wrong-site surgery was error that elicited the most successful litigation (89% of cases). Litigation relating to implantation of an incorrect prosthesis (eg right-sided prosthesis in a left knee) cost £2.9 million. Prevalence of litigation against NTEs has declined since 2007. Conclusions Improved patient-safety strategies such as the World Health Organization Surgical Checklist may be responsible for the recent reduction in prevalence of litigation for NTEs. However, addition of a specific feature in orthopaedic surgery, an ‘implant time-out’ could translate into a cost benefit for National Health Service hospital trusts and improve patient safety.


2008 ◽  
Vol 17 (6) ◽  
pp. 409-415 ◽  
Author(s):  
P Rhodes ◽  
S J Giles ◽  
G A Cook ◽  
A Grange ◽  
R Hayton ◽  
...  

Author(s):  
Maryam Tabibzadeh ◽  
Gelareh Jahangiri

Patient safety has been a major area of concern over the last decades in the healthcare industry. The number of preventable medical errors in hospitals has been noticeably high. These errors are more likely to occur in intensive care units including Operating Rooms (ORs). Wrong site surgery is one of the critical sentinel events that occur in healthcare settings. This paper fills an important gap by proposing an integrated, system-oriented methodology for proactive risk assessment of operations in ORs, to specifically analyze the wrong site surgery issue, through the identification and monitoring of appropriate Leading Safety Indicators (LSIs) to evaluate the safety of those operations and generate warning/predicting signals for potential failures. These LSIs are identified across the layers of an introduced framework, which is built on the foundation of the Human-Organization-Technology (HOT) model originally developed by Meshkati (1992). This multi-layered framework captures the contributing causes of wrong site surgery.


2013 ◽  
Vol 7 (1) ◽  
pp. 63 ◽  
Author(s):  
Seung-Hwan Lee ◽  
Ji-Sup Kim ◽  
Yoo-Chul Jeong ◽  
Dae-Kyung Kwak ◽  
Ja-Hae Chun ◽  
...  

2008 ◽  
Vol 94 (4) ◽  
pp. 6-10
Author(s):  
Robert S. Crausman ◽  
Bruce McIntyre

ABSTRACT Wrong site, side and patient surgeries continue to occur with alarming frequency. Increasing attention to the critical role of patient safety systems and a culture of safety are important. However, the individual professionals and the boards that regulate them are also important. As the patient safety movement has evolved so has our state medical board's response to wrong site, side and patient surgeries. Between 1998 and 2008 the Rhode Island Board of Medical Licensure and Discipline investigated reports of 10 wrong side, site and patient surgeries or procedures. Four were neurosurgeries, two orthopedic and one each gynecologic, ENT, ophthalmologic and vascular.


2020 ◽  
pp. 24-39
Author(s):  
Robert Yonash ◽  
Matthew Taylor

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.


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