AUTHOR BIOGRAPHIES
Matthew A. Taylor, PhD, Data Science & Research, Patient Safety Authority
ORCID iD https://orcid.org/0000-0001-6052-3098
Matthew A. Taylor (MattTaylor@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority, where he conducts research, uses data to identify patient safety concerns and trends, and develops solutions to prevent recurrence.
*Corresponding author
Molly Quesenberry, BSN, RN, Outreach & Education, Patient Safety Authority
Molly Quesenberry (moquesenbe@pa.gov) is a patient safety advisor with the Patient Safety Authority, serving healthcare facilities in the North Central region of Pennsylvania. Prior to joining PSA, she was a staff nurse, a director of nursing, a patient safety officer, and a director of quality and regulatory programs.
Robert Yonash, RN, Outreach & Education, Patient Safety Authority
Robert A. Yonash is a registered nurse and a retired patient safety advisor. He worked at the Patient Safety Authority as an advisor during 2009 to 2024 in the Southwest region of Pennsylvania.
Abstract
Background
Wrong-site surgery (WSS) remains a significant and avoidable medical error, persisting despite decades of national and international efforts to prevent it. Pennsylvania is one of the few large governments or entities that mandates reporting of patient safety events ranging from near misses to serious events.
Methods
We used the Pennsylvania Patient Safety Reporting System database to study a 10-year period (2015–2024) of wrong-site surgery events at hospitals and ambulatory surgical facilities. We reviewed and analyzed event reports for the following clinically related variables: facility type, hospital procedure location, hospital bed size, error type, clinician specialty, body region, specific body part, procedure group, and specific procedure.
Results
We identified 664 WSS events that occurred in Pennsylvania during the 10-year period of 2015–2024. The events were reported by 237 hospitals and ambulatory surgical facilities. The 16 visuals presented in this study allow for a thorough analysis that will help readers understand the extent to which WSS has a multifactorial relationship with the variables targeted in this study.
Conclusions
The present study expands upon many of the previous WSS studies by exploring novel combinations of variables across one of the largest samples of WSS events. We anticipate that stakeholders will leverage the findings to identify WSS-related factors to target and inform interventions to enhance patient safety.
Plain Language Summary
Wrong-site surgery (WSS) is defined as a “surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.” This avoidable medical error continues to be significant problem in hospitals and ambulatory surgical facilities (ASFs).
Expanding on previous WSS research, the authors of this study took a novel approach: They reviewed and analyzed 644 WSS events reported in Pennsylvania from 2015 to 2024 and identified combinations of clinically related variables, such as type of facility, hospital procedure location, error type, clinician specialty, region of the body, and specific procedure. Among their findings: Most of these WSS events occurred in hospitals rather than ASFs, distributed across operating rooms, interventional radiology, and other procedural locations. The most frequently involved specialties were interventional radiology, pain management, and orthopedics.
This study represents one of the largest samples of WSS events examined in a single study. The authors have visualized their deep-dive analysis in 16 figures, tables, and supplemental appendices to help stakeholders comprehend the many combinations of variables contributing to WSS, identify these factors in their own facility, and design interventions to improve patient safety.
Keywords: patient safety, patient harm, never event, wrong patient, wrong procedure, wrong side, WSPE, statistics, prevalence
