Pa Pat Saf Advis 2016 Dec;13(4):160-162.
Update on Wrong-Site Surgery: Reports from Ambulatory Surgical Facilities
Anesthesiology; Nursing; Surgery
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Author

Theresa V. Arnold, DPM
Manager, Clinical Analysis
Pennsylvania Patient Safety Authority

Introduction

From July 2004 through September 2016, 717 wrong-site operating room (OR) surgery events, including wrong-site anesthesia events, were reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) and analyzed by the Pennsylvania Patient Safety Authority.

Analysis of wrong-site surgery events reported to the Authority by ambulatory surgical facilities (ASFs) identified an increase in these reported events over time. The average incidence of wrong-site surgery* in Pennsylvania ORs continues to be about one event each week.1 Analysis of events reveals that ASFs reported about 29% of all wrong-site surgery events between July 2004 through June 2016 (i.e., 203 of 702); an average of one event every three weeks. Figure 1 demonstrates an increase in the percentage of wrong-site events reported from ASFs over the 12-year period. The rising trend is apparent in the most recent seven academic years (i.e., July 2009–2010 year through June 2015–2016) for which the percentage of events increased from 29% to 34.2% (i.e., 129 of 377).

Figure 1. Percentage of Wrong-Site Surgery Events Reported by Ambulatory Surgical Facilties by Academic Year

Figure 1. Percentage of Wrong-Site Surgery Events Reported by Ambulatory Surgical Facilties by Academic YearBased on the analysis of wrong-site events reported by ASFs in the most recent seven academic years (N = 129), the most commonly reported events and procedures are noted in Figure 2 and included the following:

  • Wrong side (60.5%, n = 78): blocks (by anesthesiologists and surgeons), pain management procedures, and eye procedures
  • Wrong site (31.8%, n = 41): excisions and biopsies, pain injections, hand procedures (e.g., incision placement)
  • Wrong procedures (7.8%, n = 10): tonsillectomy (e.g., instead of or in addition to adenoidectomy when only adenoidectomy was intended) and hand procedures (e.g., carpal tunnel surgery instead of trigger finger release)
  • Although ASFs and hospitals reported similar types of “wrong” events, there were two notable differences in the events reported from hospitals, which reported: (1) wrong-level spinal procedures were the most commonly reported wrong-site procedure, and (2) the wrong patient received an unintended procedure in about 2% of reported events. 
Figure 2. Type of Wrong Surgery Events Reported by Ambulatory Surgical Facilities from July 2009 through June 2016

Figure 2. Type of Wrong Surgery Events Reported by Ambulatory Surgical Facilities from July 2009 through June 2016 

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* For this analysis, the average number of wrong-site surgery events reported weekly over 12 academic years (i.e., July 2004 through June 2016) was calculated as follows: 702 events ÷ (12 × 52 weeks/year).

Update on Wrong-Site Surgery

From July 2004 through September 2016, 717 wrong-site operating room (OR) surgery events, including wrong-site anesthesia events, were reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) and analyzed by the Pennsylvania Patient Safety Authority. The three most common types of wrong-site procedures reported through PA-PSRS since July 2004 have remained consistent and account for about 50% of all wrong-site surgery events:

  1. Perioperative anesthesia blocks administered by anesthesiologists and surgeons (25.9%, n = 186 of 717)
  2. Spinal procedures (e.g., wrong level; 13.0%, n = 93)
  3. Pain-management procedures (11.4%, n = 82)

The percentage of wrong-site anesthesia blocks marginally decreased from the last update2 in June 2016 (i.e., 26.4%* to 25.9%). However, a broader analysis reveals a 6.5% improvement in the percentage of wrong-site blocks reported over the last eight quarters (i.e., from 27.7% in the second quarter of 2014–2015 to 25.9% through the first quarter of 2016–2017). Further analysis of these events in the last eight quarters revealed that 40% of wrong-site anesthesia blocks were administered by anesthesiologists and 60% by surgeons. During this two-year time period, the surgeons most commonly involved in wrong-site blocks were hand specialists, ophthalmologists, and orthopedists.

The percentage of wrong-site surgeries related to wrong-level spinal procedures and wrong-site pain-management procedures were essentially unchanged from the June update. Since July 2004, the majority of wrong-level spinal procedures were performed at the lumbar level (53%, n = 49 of 93), followed by the cervical level (27%, n = 25), and thoracic level (16%, n = 15). The spinal level was not specified in 4% (n = 4) of the reported events.

Twenty-five wrong-site surgery events were reported from Pennsylvania facilities since the last published analysis in June. One of the most common types of event reported was a spinal procedure performed at the wrong level, which accounted for 20% (n = 5 of 25); three were performed at the incorrect lumbar level and two procedures were performed at the incorrect cervical level. Anesthesia blocks accounted for 12% (n = 3), one of which was administered by an anesthesiologist on the wrong side of the body and two by hand surgeons at the wrong site of the correct hand. Similarly, pain management procedures (the majority of which were wrong-side spinal injections) accounted for 12% (n = 3) of the reported events.

Additional wrong-site surgery events reported in the most recent two quarters were as follows:

  • Wrong-side procedures (20%, n = 5 of 25); including one ureteroscopy/ureteral stent placement
  • Wrong-site procedures (16%, n = 4); including two wrong-site biopsies
  • Wrong procedures (16%, n = 4); including one ophthalmology procedure (i.e., incorrect strabismus procedure)
  • Wrong patient (4%, n = 1); a wrong (intended for another patient) gynecologic procedure

Please note: one wrong-site event was belatedly reported or recognized in each of the following academic quarters: the second quarter of 2009–2010; the first quarter of 2014–2015; and the third quarter of 2015–2016. Adjustments in the number of reported events are reflected in Figure 3. 

Figure 3. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year

Figure 3. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year ___________
* The percentage of wrong-site anesthesia blocks reported in the June 2016 update (i.e., 26.6%) differs from percentage noted above (i.e., 26.4%) because three additional wrong-site surgery events were reported to the Authority through March 2016 (i.e., 692 instead of 689). 

Summary

The data trends outlined in this update demonstrate the most common types of wrong-site events reported from Pennsylvania facilities that provide surgical services. Sharing this, and data collected internally, with surgical staff and surgeons may help to identify potential areas for process improvement. Please reference the Authority’s Wrong-Site Surgery toolkit at for patient safety tools (e.g., Self-Assessment Checklists, Observational Monitoring Tools, Principles for Reliable Performance of Correct-Site Surgery) developed to assist facilities prevent wrong-site surgery and patient harm. The Authority also has a consultation program for Pennsylvania facilities that wish to evaluate their opportunities to improve wrong-site surgery prevention processes, particularly following a wrong-site event or near miss in a surgical suite. Those interested in this program should contact the Authority office or their regional patient safety liaison (PSL). The Authority’s PSLs can help facilities assess their policies and procedures and arrange for onsite observations to evaluate surgical team compliance using the resources developed by the Authority.

Notes

  1. Quarterly update on the Preventing Wrong-site Surgery Project. Pa Patient Saf Advis 2010 Sep: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7(3)/Pages/108.aspx.
  2. Arnold TV. Update on wrong-site surgery: use patient engagement to enhance the effectiveness of the universal protocol. Pa Patient Saf Advis 2016 Jun;13(2):77-8. Also available: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2016/jun;13(2)/Pages/77.aspx
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