Wrong-Side Thoracentesis

Abstract

Prevention of wrong-site procedures and accompanying patient harm outside the operating room requires adherence to the Universal Protocol and time-outs, effective teamwork, training and education, mentoring, and patient assessment for early detection of complications. The time-outs provide protected time and place for error detection and recovery.

How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

“…Some studies warned that sometimes poorly designed action plans and measures may generate new risks and may be insufficient to prevent the occurrence of new events [5, 6, 10, 16]. In the study carried out by Hibbert et al [4], in which the effectiveness and sustainability of the proposals arising from 227 RCAs were analysed, it was found that 72% of the recommendations categorised as relevant were not formulated and that the most common recommendations did not refer to latent causes in clinical practices but to active errors.…”

Tools for the investigation of adverse events: scoping review

“…In several studies, the authors referred to the effectiveness of RCA, using quantitative and qualitative measures, as well as knowledge based on clinical experience. However, it reinforces the need to exhaustively apply this method, besides creating a database of contributing factors ( 23 – 30 ) .…”

Investigating a unilateral pleural effusion: A tale of a medical error and diagnostic delays

“…[2] It is estimated that approximately 178,000 thoracenteses are performed per year in the United States. [4] Typically, thoracocentesis is a safe procedure but can result in significant complications including pneumothorax, hemorrhage, and death. Despite these efforts, wrong side thoracocentesis can still occur.…”

“…performed a root cause analysis of 14 wrong side thoracentesis. [4] They found that absence of verification images to be cause in almost 50% of cases. Consequently, there has been a trend to the widespread implementation of ultrasonography, training, and restriction of thoracentesis to experienced health care professionals.…”

“…Consequently, there has been a trend to the widespread implementation of ultrasonography, training, and restriction of thoracentesis to experienced health care professionals. [4]…”