In this update, Pennsylvania Patient Safety Authority analysts discuss the direction of the Authority’s wrong-site surgery project, including upcoming recommendations, the incidence of anesthetic blocks and ureteral stent insertions, informative near-miss reports, how to prevent misinformation from the surgeon’s office, and operating room culture of safety.

The Authority’s published evidence-based best practice principles address deficiencies commonly found in the error analyses of wrong-site operative procedures, according to this assessment.

Minnesota’s experience in working to establish a consistent and effective time-out process as the statewide community standard in hospitals and ambulatory surgery centers has provided a number of key lessons about how to develop and implement process changes within and across organizations.

Pennsylvania Patient Safety Authority analysts reviewed the 444 wrong-site surgery reports submitted since June 2004 to identify the possible impact of 21 best practice principles for preventing wrong-site surgery.

Recent event reports exemplify the value of a properly conducted time-out. In this update, Pennsylvania Patient Safety Authority emphasizes principles that should be followed during a time-out and shares results from a survey of Pennsylvania operating room managers about their time-out processes.

The Pennsylvania Patient Safety Authority believes Pennsylvania facilities are on the right path to prevent wrong-site surgery. This article discusses trends before and after Authority interventions as well as considerations for procedures involving the knee.

Facilities may wish to use this information to inform surgeons and anesthesiologists on the rationale behind implementing best practices for following the Universal Protocol.

A reader from a Pennsylvania community teaching hospital contacts the Pennsylvania Patient Safety Authority for guidance in ongoing efforts to eliminate wrong-site surgery.

Three years have passed since the first definitive article from the Pennsylvania Patient Safety Authority on wrong-site surgery. After that initial focus on wrong-site surgery, the number of events has decreased each year. Facilities reported 14 events during the last quarter (April through June 2010).

Pennsylvania Patient Safety Authority analysts identified eight hospitals that dramatically reduced their incidence of wrong-site surgery reports. The Authority interviewed the Patient Safety Officers or other personnel at these facilities to identify their successful efforts to eliminate wrong-site surgery.

Analysis of events in the reporting system database focuses on trends involving local and regional anesthesia blocks, pain management procedures, ureteral stenting, and hand surgery.

Analysis of events in the reporting system database continues to show an encouraging decrease in the number of reports of wrong-site surgery.

There was an encouraging decrease in the number of reports of wrong-site surgeries for the third consecutive quarter to an all-time low of six reports.

Twelve wrong-site surgeries were reported during the first quarter of 2009 (Q1-2009). In this update, analytical commentary accompanies the report accounts to emphasize previously discussed principles of preventing wrong-site surgery.

Wrong-site surgery data has been updated (Q4-2008) and scripts submitted for Time-Out in the OR Competition are discussed.

Review of pen performance and sterility may provide insight for evaluating surgical site marking pens.

Previous wrong-site surgery data has been updated according to information submitted during the last quarter (Q3-2008).

Previous wrong-site surgery data has been updated according to information submitted during the last quarter (Q2-2008).

This follow-up article looks at the frequency of incorrect IOL placement reports submitted since the inception of PA-PSRS. Process issues point to team effort as being a key factor in reducing the incidence of wrong IOL implantation.

The 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.

Previous wrong-site surgery data has been updated according to information submitted during the last quarter (Q1-2008).

Previous wrong-site surgery data has been updated according to information submitted during the last quarter.

Incidence 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.

A 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.

When undergoing an operation, a patient should never have to accept these three complications as risks of surgery.

Wrong-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.

While there are many, often unavoidable reasons for delays in the operating room, addressing scheduling, transfer of care, case notification, and delays while patients are under anesthesia can help minimize the risk of procedure delays.

Notes from a panel discussion of the American College of Surgeons convey how surgeons can improve the safety of the operating team.

Experiences of Pennsylvania facilities’, conveyed through event reports, include suggestions to minimize the potential for a procedure to begin without a time out and actions to help prevent occurrence of retained foreign bodies.

Surgical preparation includes more than training and "time outs."

Procedures will only improve patient safety if team members feel empowered to act when they believe the procedures are not being followed.

Patient Safety Officers share feedback and follow-up on two topics of previous Advisory issues (i.e., insulin and tuberculin syringe confusion, time out processes).

Event reports demonstrate (1) that the time out can be useful defense against wrong-site surgery and (2) problems with implementing the time out may limit its benefits.

Excluding emergency or otherwise problematic cases, the commonly reported problem related to informed consent involved cases in which patients received several procedures during the same episode of care and consented to some procedures but not to others.

The universal protocol goes into effect July 1, 2004.

A patient was scheduled for a left total hip replacement, which was abbreviated LTHR.