Pa Patient Saf Advis 2015 Jun;12(2):79-80.
Snapshot: Quarterly Update on Wrong-Site Surgery

There were 14 reports of wrong-site surgery in Pennsylvania operating rooms (ORs) during the first quarter of 2015. This number represents a continued regression in the 2014-2015 academic year despite progress in the first quarter of the academic year (see the Figure). Half of the reported events involved injections or spinal procedures (50%, n = 7): two wrong-side paravertebral pain blocks, one intra-articular pain injection, one wrong-side preoperative regional block by an anesthesia provider, one unconsented local anesthetic injection by a surgeon despite a formal time-out, and two wrong-level spinal procedures. The most common types of all 625 wrong-site OR procedures reported to the Pennsylvania Patient Safety Authority since July 2004 have been anesthetic blocks by anesthesiologists and surgeons (n = 172), wrong-level spinal procedures (n = 77), and pain management procedures (n = 71)—the persistent top three types of wrong-site operating suite procedures.

Figure. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year



Confirmation bias and misperception in the OR are repetitive problems, as illustrated by the following report:*

A surgical arthroscopy of the left ankle was scheduled. The patient was taken to the operating room. Incorrect right leg had tourniquet applied and injected with 5 mL of 1% lidocaine and 5 mL of 0.25% Marcaine when circulator realized incorrect site/side injected. Correct left ankle was then injected and surgery completed.

* The details of the Pennsylvania Patient Safety Reporting System event narratives in this article have been modified to preserve confidentiality.

Although monitoring the more than 600 wrong-site surgical events reported since July 2004 has allowed Authority analysts to trend and research common event types that led to wrong-site surgery and to issue 21 evidence-based best practices (see “Principles for Reliable Performance of Correct-Site Surgery”), the Authority receives equally valuable reports that showcase near-miss or good catch events.

An example of a reported good catch reflects staff empowerment to “stop the line” when a concern for patient safety and the potential for a wrong-site event is recognized. The following deidentified report is an example of staff assertiveness to ensure that best practices are maintained for surgical site marking:

Surgeon marked top of patient’s left knee instead of patient’s left foot. Patient using chlorhexidine wipes preoperatively, and surgeon did not want to wait to mark correct site. Site marking removed by nursing staff, and surgeon was informed to re-mark the correct site.


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