J Korean Med Assoc.  2015 Feb;58(2):110-115. 10.5124/jkma.2015.58.2.110.

Prevention of wrong site, wrong procedure, wrong patient surgery and time-out

• Chung YS

• KMID: 1958372
• DOI: http://doi.org/10.5124/jkma.2015.58.2.110

Abstract

While errors in surgical site or patient identification should not occur, they are some of the most common sentinel events. These events affect not only the patient but also the surgeon and hospital. The exact incidence of surgical errors cannot be measured because measurement depends on voluntary reporting. There have been many efforts to reduce these surgical errors. For example, Universal protocol and time-out just before surgery begins have been introduced. It is also essential to mark the surgical site in a uniform manner. Despite these processes,surgical errors still happen for many reasons. One of most common root causes is communication error. It is essential to use precise communication and to speak up if something is wrong. Hospitals and surgeons should use leadership to involve their teams in a patient safety culture. Not only the system but also this patient safety culture can reduce the incidence of surgical error.

Keyword

Patient safety; Surgery; Safety management

MeSH Terms

Humans
Incidence
Leadership
Medical Errors
Patient Safety
Safety Management

Reference

1. Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006; 141:353–357.

2. Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003; 85:193–197.

3. Dambrosia R, Kilpatrick J. Medical errors and wrong-site surgery. Orthopedics. 2002; 25:288.

4. Agency for Healthcare Research and Quality. Wrong-site, wrong-procedure, and wrong-patient surgery [Internet]. Rockville: Agency for Healthcare Research and Quality;2014. cited 2014 Dec 12. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=18.

5. Joint Commission. Sentinel event data summary [Internet]. Oakbrook Terrace: Joint Commission;2014. cited 2014 Dec 12. Available from: http://www.jointcommission.org/assets/1/18/2004_to_2014_2Q_SE_Stats_-_Summary.pdf.

6. Nance JJ. Why hospitals should fly: the ultimate flight plan to patient safety and quality care. Bozeman: Second River Healthcare Press;2008.

7. Lewis BD. Initial evidence reduced levels of wrong sided surgery [Internet]. Quebec: Canadian Orthopaedic Association;2014. cited 2014 Dec 12. Available form: http://www.coa-aco.org/library/practice-management/initial-evidence-reduced-levels-of-wrong-sided-surgery.html.

8. Canale ST, DeLee J, Edmonson A, Fountain SS, Weiland AJ, Bartholomew L, Thomason J, Olds Glavin K, Wieting MW, Heckman JD, Gelberman RH. The American Academy of Orthopaedic Surgeons report of the task force on wrong-site surgery. Rosemont: American Academy of Orthopaedic Surgeons;1998. 1998.

9. Ring DC. Confirm before you cut: for surgical safety, confirmation is key [Internet]. Rosemont: American Academy of Orthopaedic Surgeons;2014. cited 2014 Dec 12. Available from: http://www6.aaos.org/news/PDFopen/PDFopen.cfm?page_url=http://www.aaos.org/news/aaosnow/may13/clinical7.asp.

10. North American Spine Society. Sign, mark & X-ray: prevention of wrong-site spinal surgery now [Internet]. Burr Ridge: North American Spine Society;2014. cited 2014 Dec 12. Available from: https://www.spine.org/Pages/ResearchClinicalCare/PatientSafety/SignMarkXray.aspx.

11. Joint Commission on Accreditation of Healthcare Organizations. Universal protocol for preventing wrong site, wrong procedure, wrong person surgery. Oakbrook: Joint Commission on Accreditation of Healthcare Organizations;2007.

12. Joint Commission International. Joint Commission International accreditation standards for hospitals. 4th ed. Oakbrook Terrace: Joint Commission Resources;2011.

13. World Health Organization. The second global patient safety challenge [Internet]. Geneva: World Health Organization;2014. cited 2014 Dec 12. Available from: http://www.who.int/patientsafety/safesurgery/knowledge_base/SSSL_Brochure_finalJun08.pdf.

14. Korea Institute for Healthcare Accreditation. Medical Institute Accreditation Standards ver. 1.0. Seoul: Korea Institute for Healthcare Accreditation;2010.

15. Korea Institute for Healthcare Accreditation. Medical Institute Accreditation Standards ver. 2.0. Seoul: Korea Institute for Healthcare Accreditation;2014.

16. Joint Commission. Universal protocol [Internet]. Oakbrook Terrace: Joint Commission;2014. cited 2014 Dec 12. Available from: http://www.jointcommission.org/standards_information/up.aspx.

17. James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am. 2012; 94:e2.

18. Stahel PF, Sabel AL, Victoroff MS, Varnell J, Lembitz A, Boyle DJ, Clarke TJ, Smith WR, Mehler PS. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010; 145:978–984.

19. Lee SH, Kim JS, Jeong YC, Kwak DK, Chun JH, Lee HM. Patient safety in spine surgery: regarding the wrong-site surgery. Asian Spine J. 2013; 7:63–71.

20. Ockerman J, Pritchett A. A review and reappraisal of task guidance: aiding workers in procedure following. Int J Cogn Ergon. 2000; 4:191–212.