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

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 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, e.g. what arm are we operating on?, as opposed to questions that require passive answers e.g. 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.

For more information on appropriate site markings and the complete findings from the six facility site visits, go to the article "Insight into Preventing Wrong-Site Surgery" of the 2007 December Patient Safety Advisory at

Facilities interested in learning more to prevent wrong-site surgery can also go to the Authority's website for more information that includes: A graph of cumulative wrong-site surgery events in Pennsylvania which will be updated quarterly; stand alone copies of figures discussing the flow and awareness of information in the operating room; the ongoing comparative results of detailed reports of wrong-site surgery and near misses, updated quarterly; a stand-alone copy of a self-assessment checklist for programs to prevent wrong-site surgery; access to all Patient Safety Advisory articles regarding wrong-site surgery; previously released "Doing the 'Right' Things to Correct Wrong-Site Surgery" video; and a contact link to discuss with the Authority's PA-PSRS team your assessments, successes, failures, other experiences, opinions and questions.

The Authority's quarterly 2007 December Advisory contains more articles developed from data submitted through real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights of this and other articles include:

Preventing MRSA: More than 1,700 reports related to methicillin-resistant Staphylococcus aureus (MRSA), including 14 deaths, have been reported to the Authority since June 2004 through October 2007. The reports show that in 90 percent of the cases, a MRSA screening was not noted as having been done when the patient was admitted to the facility. In about 13 percent of reports where MRSA was found upon admission, the information about the infection was not communicated to other healthcare workers. Additional prevention tips for patients can be found on the Authority's website at under "Consumer Tips."

Problems Associated with Regional Nerve Blockers: The interscalene block (ISB) is a regional anesthetic technique that provides pain relief to the shoulder and lateral regions of the arm and forearm. However, the Authority has received reports of the complications associated with the nerve block that includes: chest pain, chest tightness, seizure, irregular heartbeat and ineffective pain control. Proper technique can reduce these complications.

Drug Overdoses Still Happen with Smart Infusion Pump Technology: Even when computerized systems are used to reduce drug overdoses they sometimes still occur, particularly with intravenous high-alert medications like Heparin. One of the most common reasons for the overdose is due to misprogrammed infusion pumps.

CT Scans May Affect Pacemakers and other Implantable Electronic Devices: The Authority has received reports of patients experiencing a shock during a CT scan if they have an implantable electronic device (e.g. Pacemaker). The interference may be due to new, more powerful scanners being used to obtain a faster scan.

For a copy of the 2007 December Patient Safety Advisory go to 7_advisory_v4_n4.pdf.

For more information on the Patient Safety Authority or previous Patient Safety Advisories, visit the Authority's website at

SOURCE Patient Safety Authority
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