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Patient Safety Authority Visits Facilities for Information on Wrong-Site Surgery
Date:1/10/2008

Analysis shows facilities can learn much from each other in regard to the right way and wrong way to prevent wrong-site surgeries

HARRISBURG, Pa., Jan. 10 /PRNewswire-USNewswire/ -- While reports of wrong-site surgeries in the Commonwealth 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 th
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SOURCE Patient Safety Authority
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