HARRISBURG: Wrong-site surgery data received by the Patient Safety Authority shows that every other day in Pennsylvania healthcare facilities an actual adverse event or near miss of a wrong-site surgery occurs. The Authority released its 2007 June Patient Safety Advisory containing the data in a press conference held in Harrisburg today.
“To be frank, wrong-site surgeries in Pennsylvania should never occur. However, every other day in Pennsylvania we have a report of a wrong-site surgery being caught either before or after the start of an operation,” said Dr. Stan Smullens, chief medical officer of the Jefferson Health System and vice-president of the Patient Safety Authority Board of Directors. “However, we are not alone. Wrong-site surgeries are no more common in Pennsylvania than they are in other states. We also have in common with other states the problem of trying to fix them.”
In a 30-month time period (June 2004 –December 2006) the Authority received 427 near misses and serious events of wrong-site surgeries. Of those, 253 were near misses or did not reach the patient.
“Of those events that reached the patient in the operating room, sixty-nine percent were wrong side surgeries, fourteen percent were wrong body part surgeries, nine percent were wrong procedure and eight percent were wrong patient,” added Smullens. “The most common sites where the wrong-site occurred were extremities, eyes and spine. Orthopedic and ophthalmologic procedures were the most common for wrong-site surgeries.”
Smullens added that risk factors for wrong-site surgery include: multiple procedure and/or multiple surgeons; communication breakdowns; time pressures; incomplete preoperative assessments; and organizational cultural factors that are not conducive to promoting teamwork such as an attitude that surgeons’ decisions should never be questioned. However, he added that in many reports the patient or family member was responsible for correcting information that prevented the wrong-site surgery from occurring. The Authority has provided a consumer tip sheet for patients and families.
“We know that patients and family members have been important components in stopping wrong-site surgeries from happening,” said Smullens. “So, we’ve developed a consumer tip sheet that provides patients and family members with advice to ensure they participate in their healthcare and reduce the likelihood of a wrong-site surgery.”
Furthering the preventive cause, Dr. Anthony Ardire, senior vice president of Quality and Patient Safety at Lehigh Valley Health System, spoke about what his organization has done to reduce and eliminate wrong-site surgeries.
Dr. Ardire listed several steps that contributed to the Lehigh Valley Health System’s success in reducing and eliminating wrong-site surgeries. One crucial step is the commitment from the organization’s leadership to patient safety.
“At Lehigh Valley we have full support from senior administrative and clinical leadership on patient safety issues, in particular, wrong-site surgery prevention,” Ardire said. “Wrong-site surgery events are thoroughly evaluated with a formal root-cause analysis and are reported regularly to our organization’s Performance Committee and Board of Directors.”
Other important steps include collaborations that involve strategically placed posters as visual reminders and special stickers that promote time outs prior to surgery.
A time out is the last in a series of steps launched in July 2004 as part of the Joint Commission’s Universal Protocol for Preventing Wrong-Site, Wrong Procedure and Wrong Person Surgery™. The step requires that a “time out” occur to verify correct patient, correct procedure and correct site before any surgery begins.
“It surprised many that since the Joint Commission launched its Universal Protocol, there has been a sustained increase, not decrease, in the number of reported cases of wrong-site surgeries,” added Ardire. “While some of the rise may be due to increased reporting, the fact remains that the incidence and frequency of this problem is not decreasing.”
Ardire said since the implementation 18 months ago of Lehigh Valley Hospital’s wrong-site surgery and procedure protocols, they have eliminated all wrong-site surgery and wrong-site procedures.
“It does take diligence on everyone’s part to prevent wrong-site surgeries and procedures,” Ardire said. “We believe you can’t rely solely on education. Visual reminders, tracking and investigation of all events and near misses and multi-disciplinary collaboration are required.”
Michael Doering, interim executive director of the Patient Safety Authority, spoke about the Authority’s plans to reduce and eliminate wrong-site surgeries in Pennsylvania.
“This summer, the Authority will begin to visit and interview several volunteer facilities on their wrong-site surgery protocols,” Doering said. “Once we gather this comprehensive information, we will have a better understanding of what works and what doesn’t in preventing wrong-site surgeries. Based upon this information we will provide guidance to facilities that we believe will help prevent wrong-site surgeries.
“We anticipate testing the effectiveness of the new guidance with volunteer facilities. Once we have evidence the new guidance is working, we will encourage and help facilities implement the new guidance,” Doering added.
Lynn Gurski Leighton, vice president of Professional and Clinical Services for the Hospital & Healthsystem Association of Pennsylvania (HAP), also participated at the press conference in support of the Authority and its patient safety initiatives to reduce wrong-site surgery. Carolyn F. Scanlon, president and chief executive officer of HAP, could not attend but gave the following statement.
"Patient safety is an integral part of every hospital's mission—patient safety starts with leadership and is carried through to every person in the organization. Patient safety must be owned, valued, tested and constantly improved," said Carolyn F. Scanlon, President and Chief Executive Officer of The Hospital & Healthsystem Association of Pennsylvania.
"As partners with the Patient Safety Authority, committed to ongoing education and collaboration to reduce medical errors and create environments for learning and improving care, we support the Authority's work on the issue of wrong-site surgery. While a rare event in health care, wrong site surgery has far-reaching consequences for patients and caregivers. The Patient Safety Advisory points to multiple risk factors and system breakdowns that can occur in the complex world of medicine. And from this information, hospitals and health systems will continue to improve their protocols and practices to ensure such devastating mistakes do not occur."
In addition, the 2007 June Advisory wrong-site surgery article “Doing the ‘Right’ Things to Correct Wrong-Site Surgery,” is accompanied by a narrated PowerPoint presentation which further details the breakdown of wrong-site surgery cases in Pennsylvania. To access the PowerPoint presentation and other educational resources for preventing wrong-site surgery click here.
Other articles in the 2007 June Patient Safety Advisory include: “Mismanagement of Breast Milk”; “Propofol Infusion Syndrome: A Rare but Potentially Fatal Reaction”; “Fentanyl Transdermal System: Taking Another Look”; Strategies to Minimize Vascular Complications following a Cardiac Catherization”; and “In Vitro Hemolysis: Delays May Pose Safety Issues.” An additional educational toolkit is available for healthcare providers for the "Mismanagment of Breast Milk" article by clicking here.
For a copy of the June 2007 Patient Safety Advisory click here or for more information on the Patient Safety Authority, go to www.patientsafetyauthority.org.