AUTHOR BIOGRAPHIES
Matthew A. Taylor, PhD, Patient Safety Authority
Matthew A. Taylor (MattTaylor@pa.gov) is a research scientist for the Patient Safety Authority (PSA), where he conducts research, uses data to identify patient safety concerns and trends, and develops solutions to prevent recurrence. He is a core team member of PSA’s Center of Excellence for Improving Diagnosis. Prior to joining the PSA, Taylor was a scientific writer and research specialist at the University of Pittsburgh School of Pharmacy, and he has served fellowships at the Centers for Disease Control and Prevention (CDC) and the VA Pittsburgh Healthcare System. His expertise in data analysis and research covers a range of topics, including patient safety, public health, employee training, process efficiency, human factors, workplace culture/climate, behavior change interventions, and organizational management.
*Corresponding author
Robert A. Yonash, RN, Patient Safety Authority
Robert A. Yonash is a registered nurse and has been with the Patient Safety Authority (PSA) since 2009 as the patient safety advisor for the Southwest region of Pennsylvania, working with his regional medical facilities to assist them in the reduction and elimination of medical errors. In this role, Yonash has been assigned to a number of projects, including the statewide Centers for Medicare & Medicaid Services Partnership for Patients and the Hospital Engagement Networks Wrong-Site Surgery Prevention Collaboration and the PSA/Pennsylvania Society of Anesthesiologists Wrong-Site Block Initiative. He is a Core Team Lead for the PSA’s Center of Excellence for Improving Diagnosis, providing guidance and support for healthcare facilities, systems, providers, and patients to decrease harm from diagnostic errors. Yonash is a member of the American Society of Professionals in Patient Safety and has attained certification as a Certified Professional in Patient Safety (CPPS) and Certified Six Sigma Lean Green Belt in Healthcare. He is also a master trainer in TeamSTEPPS.
Abstract
Background
The accuracy of informed consent and procedural schedule are important components in a process for preventing wrong-site surgery.
Methods
In our study of a four-year period, we used the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to explore the occurrence of consent and/or schedule errors at all licensed hospitals and ambulatory surgical facilities (ASFs) in Pennsylvania. We also evaluated the reports for consent and schedule error subtypes: side, procedure, site, and patient.
Results
Over a four-year period, 1,166 event reports described a consent and/or schedule error, and 86% of the reports were from hospitals and 14% were from ASFs. Among the 1,166 reports, 56% described a schedule error, 34% had a consent error, and 10% involved both error types. In the sample of reports, the frequency of error subtypes were ranked in the following sequence: side (69%), procedure (24%), site (4%), and patient (3%). The analysis also revealed similarities and differences in the distribution of error types and subtypes across hospitals and ASFs.
Conclusions
Based on the results, it is evident that consent and schedule errors are issues across many healthcare facilities. The findings by error subtype (side, procedure, site, patient) show some similarity in distribution with previous studies of wrong-site surgery events. We recommend that readers review Table 4 and Table 5 for a brief literature review of risk factors for consent and schedule errors and strategies for preventing and detecting the occurrence of those errors, respectively.
