Wrong-Site Surgeries Are Preventable

Croteau, Richard J.

doi:10.1001/archsurg.142.11.1111-b

Cited by 8 publications

(7 citation statements)

References 1 publication

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“…21 This may in part reflect the increased case volume of these specialties or the bilateral or multilevel (ie, spine) nature of the procedures conducted by these specialists. A recent survey-based study demonstrated that medical errors and adverse events continue to be a common occurrence in otolaryngology, finding that otolaryngology cases constitute 0.3% to 4.5% of all WSS.…”

Section: Discussionmentioning

confidence: 99%

Wrong‐Site Surgery in California, 2007‐2014

Moshtaghi

Haidar

Sahyouni

et al. 2017

Otolaryngol.--head neck surg.

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Objective. The implementation of a universal surgical safety protocol in 2004 was intended to minimize the prevalence of wrong-site surgery (WSS). However, complete elimination of WSS in the operating room continues to be a challenge. The purpose of this study is to evaluate the prevalence and etiology of WSS in the state of California. Study Design. A retrospective study of all WSS reports investigated by the California Department of Public Health between 2007 and 2014. Methods. Prevalence of overall and specialty-specific WSS, causative factors, and recommendations on further improvement are discussed. Results. A total of 95 cases resulted in incident reports to the California Department of Public Health and were included in our study. The most common errors were operating on the wrong side of the patient’s body (n = 60, 62%), performing the wrong procedure (n = 21, 21%), operating on the wrong body part (n = 12, 12%), and operating on the wrong patient (n = 2, 2%). WSS was most prevalent in orthopedic surgery (n = 33, 35%), followed by general surgery (n = 26, 27%) and neurosurgery (n = 16, 17%). All 3 otolaryngology WSS cases in California are associated with the ear. Conclusion. WSS continues to surface despite national efforts to decrease its prevalence. Future research could establish best practices to avoid these “never events” in otolaryngology and other surgical specialties.

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Section: Discussionmentioning

confidence: 99%

Wrong‐Site Surgery in California, 2007‐2014

Moshtaghi

Haidar

Sahyouni

et al. 2017

Otolaryngol.--head neck surg.

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“…[11][12][13]19 Previous reports [19][20][21] have revealed that only approximately one-third of all wrongsite surgery cases result in legal action and estimated that the Joint Commission sentinel event database comprises just 2% of all wrong-site procedures occurring in the United States. 11,22 The present study was designed to analyze the frequency, root causes, and outcomes of wrong-site and wrongpatient procedures based on a comprehensive, prospective insurance database of 27 370 physician self-reported adverse occurrences in Colorado from 2002 through 2008.…”

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confidence: 99%

Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era

Stahel¹

2010

Arch Surg

136

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“…The same article stated that half of the surgeons in one facility resisted site marking and disagreed about how to mark the site. This deliberate violation could lead to errors, according to the findings of previous research 3,16 …”

Section: Discussionmentioning

confidence: 86%

“…The Joint Commission recognized in 2005 that procedural compliance was among the top three root causes for wrong site surgeries 3 . Beginning in 1995 through 2004, procedural compliance documented in Joint Commission‐accredited facilities was reported at 70%.…”

Section: Statement Of Purposementioning

confidence: 99%

Determining the State of Knowledge for Implementing the Universal Protocol Recommendations: An Integrative Review of the Literature

Conrardy

Brenek²,

Myers³

2010

AORN Journal

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The purpose of this study was to determine the current state of knowledge concerning the implementation of the Joint Commission's Universal Protocol. We conducted an integrative review of the literature through a systematic search of the National Library of Medicine (ie, PubMed) database to identify empirical and theoretical documents that discussed the implementation process for the Universal Protocol. The current state of knowledge varies from facility to facility, and we noted significant trends, gaps, and areas of concern in the implementation process. Successful implementation of the Universal Protocol has the following elements: a multidisciplinary team approach, active staff/patient participation, supportive hospital administration/leadership, and active communication that promotes a healthy work environment.

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Wrong-Site Surgeries Are Preventable

Cited by 8 publications

References 1 publication

Wrong‐Site Surgery in California, 2007‐2014

Wrong‐Site Surgery in California, 2007‐2014

Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era

Determining the State of Knowledge for Implementing the Universal Protocol Recommendations: An Integrative Review of the Literature

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