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Preventing Wrong-Site Surgery
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Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process.
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Principles for Reliable Performance of Correct-Site SurgeryIf surgical facilities are to hold their gains in consistently performing correct-site surgery, these principles for reliable performance of correct-site surgery, identified by the Pennsylvania Patient Safety Authority during its Preventing Wrong-Site Surgery Project, should be consistently followed. Wrong Spinal Level Analysis FormThis form is an addendum to the "Wrong-Site/-Side Surgery Error Analysis Form" and should complement the main form, as applicable. Wrong Ureter Analysis FormThis form is an addendum to the "Wrong-Site/-Side Surgery Error Analysis Form" and should complement the main form, as applicable. How Can You Prevent Wrong-Site Surgery?Surgeons or facilities can give this brochure to preoperative patients so that they understand why so many providers ask the same questions. Facility-specific logos or contact information can be added to personalize the brochure. OR Scheduling FormThis sample form includes suggested elements pertinent to scheduling cases for the operating room. Preoperative ChecklistThis sample checklist includes suggested elements pertinent to checking patient information, medical documentation, and surgical information. Day of Surgery: Standardized Independent Verification 1This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information. It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure. Day of Surgery: Standardized Independent Verification 2This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information. It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure. |
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Table 1. Marking Experiences Listed by MarkersThe Pennsylvania Patient Safety Authority surveyed operating room managers about their experiences with using various marking pens with various skin preparation agents. The following table lists experiences according to markers. |
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Editorial: WHO Surgical Safety ChecklistThe Second Global Patient Safety Challenge: Safe Surgery Saves Lives initiative introduced this checklist, designed to catch omissions in the actions supporting an operation before the patient suffers harm. Insight into Preventing Wrong-Site SurgeryIncidence of wrong-site surgery has decreased in Pennsylvania, but PA-PSRS continues to receive reports of its occurrence. PA-PSRS’s analysis suggests opportunities for wrong-site surgery prevention. Query on Wrong-Site SurgeryA reader questions whether the analysis of wrong-site surgery events reported in Pennsylvania and the resulting article adequately addresses the responsibility of physicians in preventing wrong-site surgery. Doing the Right Things to Correct Wrong-Site SurgeryWrong-site surgery that touches the patient is expected to occur once a year in the operating room of a 300-bed hospital. Considering wrong-site surgery prevention processes as a whole is an important strategy to preventing wrong-site surgery. |
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