Actual and near-miss wrong-site surgery happens every other day in Penn.
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 this week.

“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.

Smullens said 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. 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. However, the number of reported cases of wrong-site surgeries has increased. Some of that may be explained by increased reporting, but it is clear that the incidence and frequency is not decreasing.

The authority is set to visit and interview several volunteer facilities on their wrong-site surgery protocols this summer. Based on their findings, the authority will develop guidance to facilities to help prevent wrong-site surgeries.