While reports of wrong-site surgeries decreased during 2007, some facilities continue to report wrong-site surgeries that may have been prevented had they followed protocols implemented by other Pennsylvania facilities that have been successful in preventing wrong-site surgeries in their institutions, according to analysis published by the Patient Safety Authority in its December 2007 Patient Safety Advisory.

Since the authority first published the frequency of wrong-site surgeries in Pennsylvania in its June 2007 Patient Safety Advisory, a more in-depth analysis of  facilities was conducted that shows some facilities are doing the right things to prevent wrong-site surgery, while others still have system weaknesses that make wrong-site surgery possible.

The authority said it visited six volunteer hospitals – four of the hospitals had more than one report of a wrong-site surgery within a two and a half year time period and two hospitals had no reports of a wrong-site surgery during the reporting period. The authority’s team, consisting of the Pennsylvania Patient Safety Reporting System’s clinical director and two nurse analysts spent one day at each of the six facilities with a confidentiality agreement consistent with Act 13. 

“From our recent observations, wrong-site errors usually result from either misinformation prior to the patient getting into the operating room or misperceptions of hospital staff once the patient is in the operating room,” John Clarke, MD, clinical director of the Patient Safety Authority said. “Misperception can occur from confusion regarding right or left and the failure to question authority, among other reasons.” 

“We noted that wrong-site surgery errors were associated with the failure to identify incorrect information in the documents related to surgery, such as the schedule, consent and patient’s history and physical examination before the operation,” said Clarke. “Hospitals that check for errors at every opportunity have more success in preventing misinformation from reaching the operating room—and the more independent the checks the better.”

Other observations in regard to the site marking include that the mark should be made accurately and in a way consistent with the facility’s protocol; the mark should be consistent with all documents completed prior to surgery; and the mark should be made by someone who knows about the procedure and hospital protocol.