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Patient Safety Authority
333 Market Street
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Harrisburg, PA 17120


Phone: 717-346-0469
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Query on Wrong-Site Surgery
PA PSRS Patient Saf Advis 2007 Sep;4(3):72. 
 

PA-PSRS Patient Safety Advisory staff recently received a query from a reader in response to the article “Doing the ‘Right’ Things to Correct Wrong-Site Surgery” that appeared in the June 2007 issue. The reader questioned whether the analysis of wrong-site surgery events reported in Pennsylvania and the resulting article adequately addressed the responsibility of physicians in preventing wrong-site surgery. Comments questioning responsibility in wrong-site surgery cases also appeared on the ABC Web site’s “Talk Back” section in response to a Good Morning America piece on wrong-site surgery that aired August 9, 2007;1  this television spot included commentary from John Clarke, MD, editor and clinical director, PA-PSRS. 

The emphasis of the PA-PSRS Patient Safety  Advisory has been on improving healthcare systems so that they can reliably deliver the right care to the right patient at the right time. Educating individual providers about what they can do to prevent or mitigate errors is useful, but not sufficient. It is our position that more improvement comes from improving a system than from improving the performance of individuals within an existing system. Nowhere is this more obvious than with “at-risk behavior.” Individuals should be educated about approaches that increase the risks of error and should be expected not to use them. However, facilities have the responsibility to monitor for at-risk behavior, counsel those who do it, provide encouragements and incentives for low-risk behavior, and provide barriers to keep at-risk behaviors from affecting patients. Examples abound, but one directly related to wrong-site surgery is that some hospitals will not load the scalpel blade into the handle until after the surgeon has done the time-out (see the aforementioned article in the June 2007 Advisory). Physicians, frequently not employees of the healthcare facility, should not be participating in at-risk behavior. However, physicians have a relationship with the facility predicated on explicitly stated behavior, and the facility has a responsibility to its patients to protect them against at-risk behavior by providers, including those on medical staff. We feel that arguments about who has more responsibility for patient safety misses the point that safety is the commitment of a system that includes both facilities and their medical staffs. 

The actions of the surgeons in the operating room (OR) were cited as the leading factor in wrong-site surgery in the article (under the section on “System Breakdowns”), and these actions were illustrated by several examples. When we compared 174 wrong-site surgery events with 253 wrong-site surgery near misses, we found that physician behavior in the operating room was the leading cause of wrong-site surgery events. Most of these events (92) involved the behavior of the surgeon in the operating room, with another 29 involving the behavior of the anesthesia provider. This detailed scientific study was presented to the American Surgical Association and was published in the September 2007 issue of the Annals of Surgery. Almost all of the recommendations involve actions by the surgeons.2 Publication of our analysis in this surgical journal was specifically chosen to reach and influence the thinking of practicing surgeons. PA-PSRS staff hope that facilities will take advantage of the information, which is available electronically (http://www.annalsofsurgery.com), to develop a strong working relationship between the OR physicians and support staff to commit to a safe patient experience in the OR. 

Notes

  1. Talk back [comment section online]. In: Surgical mishaps: wrong-site operations [television transcript online]. ABC News Good Morning America. 2007 Aug 9 [cited 2007 Aug 16]. Available from Internet: http://abcnews.go.com/GMA/OnCall/story?id=3459845&page=1.
  2. Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg 2007 Sep;246(3):395-405.
 
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THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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