Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities

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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A History of Wrong Site Surgery in Rhode Island

Journal of Medical Regulation ◽

10.30770/2572-1852-94.4.6 ◽

2008 ◽

Vol 94 (4) ◽

pp. 6-10

Author(s):

Robert S. Crausman ◽

Bruce McIntyre

Keyword(s):

Patient Safety ◽

Rhode Island ◽

Critical Role ◽

Wrong Site Surgery ◽

Wrong Side ◽

History Of ◽

The Individual ◽

Safety Systems ◽

Wrong Site

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.

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Analysis and outcomes of wrong site thyroid surgery

BMC Surgery ◽

10.1186/s12893-021-01247-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Gianlorenzo Dionigi ◽

Marco Raffaelli ◽

Rocco Bellantone ◽

Carmela De Crea ◽

Carlo Enrico Ambrosini ◽

...

Keyword(s):

Thyroid Surgery ◽

Rare Event ◽

Lymph Node Excision ◽

Legal Action ◽

Preventive Strategies ◽

Case Presentation ◽

Wrong Site Surgery ◽

Wrong Side ◽

Low Volume ◽

Wrong Site

Abstract Background In thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature. Case presentation This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement. Conclusion WSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented.

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Common general surgical never events: analysis of NHS England never event data

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzab045 ◽

2021 ◽

Vol 33 (1) ◽

Author(s):

Islam Omar ◽

Rishi Singhal ◽

Michael Wilson ◽

Chetan Parmar ◽

Omar Khan ◽

...

Keyword(s):

Breast Implants ◽

Skin Condition ◽

Chest Drain ◽

Event Data ◽

Wrong Site Surgery ◽

Wrong Side ◽

Retained Foreign Body ◽

Never Events ◽

Never Event ◽

Wrong Site

Abstract Background There is little available data on common general surgical never events (NEs). Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. Objectives The purpose of this study was to identify common general surgical NEs from the data held by the National Health Service (NHS) England. Methods We analysed the NHS England NE data from April 2012 to February 2020 to identify common general surgical NEs. Results There was a total of 797 general surgical NEs identified under three main categories such as wrong-site surgery (n = 427; 53.58%), retained items post-procedure (n = 355; 44.54%) and wrong implant/prosthesis (n = 15; 1.88%). We identified a total of 56 common general surgical themes—25 each in the wrong-site surgery and retained foreign body categories and six in wrong implants category. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117; 27.4%). There were 18 wrong-side chest drains (4.2%) and 18 (4.2%) wrong-side angioplasty/angiograms. There were seven (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and six (1.4%) instances of biopsy of the cervix rather than the colon or rectum. Retained surgical swabs were the most common retained items (n = 165; 46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guide wires, 26 (7.3%) surgical needles and 9 (2.5%) surgical drains. Wrong stents were the most common (n = 9; 60%) wrong implants followed by wrong breast implants (n = 2; 13.3%). Conclusion This study found 56 common general surgical NEs. This information is not available to surgeons around the world. Increased awareness of these common themes of NEs may allow for the adoption of more effective and specific safeguards and ultimately help reduce their incidence.

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How a System for Reporting Medical Errors Can and Cannot Improve Patient Safety

The American Surgeon ◽

10.1177/000313480607201118 ◽

2006 ◽

Vol 72 (11) ◽

pp. 1088-1091 ◽

Cited By ~ 16

Author(s):

John R. Clarke

Keyword(s):

Patient Safety ◽

Medical Errors ◽

Systems Of Care ◽

Improve Patient Safety ◽

Integrated System ◽

Ease Of Use ◽

Near Misses ◽

Safety Reporting ◽

Ideal System ◽

Reporting Systems

The Institute of Medicine has recommended systems for reporting medical errors. This article discusses the necessary components of patient safety databases, steps for implementing patient safety reporting systems, what systems can do, what they cannot do, and motivations for physician participation. An ideal system captures adverse events, when care harms patients, and near misses, when errors occur without any harm. Near misses signal system weaknesses and, because harm did not occur, may provide insight into solutions. With an integrated system, medical errors can be linked to patient and team characteristics. Confidentiality and ease of use are important incentives in reporting. Confidentiality is preferred to anonymity to allow follow-up. Analysis and feedback are critical. Reporting systems need to be linked to organizational leaders who can act on the conclusions of reports. The use of statistics is limited by the absence of reliable numerators and denominators. Solutions should focus on changing the cultural environment. Patient safety reporting systems can help bring to light, monitor, and correct systems of care that produces medical errors. They are useful components of the patient safety and quality improvement initiatives of healthcare systems and they warrant involvement by physicians.

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Patient safety awareness among 309 surgeons in Enugu, Nigeria: a cross-sectional survey

Patient Safety in Surgery ◽

10.1186/s13037-019-0216-2 ◽

2019 ◽

Vol 13 (1) ◽

Author(s):

Arinze Duke George Nwosu ◽

Fidelis Anayo Onyekwulu ◽

Elias Chikee Aniwada

Keyword(s):

Patient Safety ◽

Public Health Problem ◽

Professional Status ◽

Major Public Health Problem ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Safety Issues ◽

Wrong Site Surgery ◽

Safety Awareness ◽

Wrong Site

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.

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Has the Culture of Patient Safety Changed Wrong-Site Surgery?

JBJS Orthopaedic Highlights Spine Surgery ◽

10.2106/jbjs.ss.l.00456 ◽

2012 ◽

Vol 1 (1) ◽

pp. e3

Author(s):

Paul A. Anderson

Keyword(s):

Patient Safety ◽

Wrong Site Surgery ◽

Wrong Site

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The use of collaboration to implement evidence-based safe practices

Journal of Public Health Research ◽

10.4081/jphr.2013.e26 ◽

2013 ◽

Vol 2 (3) ◽

pp. 26 ◽

Cited By ~ 1

Author(s):

John R. Clarke

Keyword(s):

Patient Safety ◽

Best Practices ◽

Operating Room ◽

Medical Error ◽

Near Miss ◽

Evidence Based ◽

Wrong Site Surgery ◽

Eastern Pennsylvania ◽

One Year ◽

Wrong Site

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.

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Litigation costs of wrong-site surgery and other non-technical errors in orthopaedic operating theatres

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2015.0045 ◽

2015 ◽

Vol 97 (8) ◽

pp. 592-597 ◽

Cited By ~ 3

Author(s):

WD Harrison ◽

B Narayan ◽

AW Newton ◽

JV Banks ◽

G Cheung

Keyword(s):

Patient Safety ◽

National Health Service ◽

Health Service ◽

National Health ◽

Improve Patient Safety ◽

World Health ◽

Wrong Site Surgery ◽

Technical Errors ◽

Operating Theatres ◽

Wrong Site

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.

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