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Getting surgery right
Journal article   Open access   Peer reviewed

Getting surgery right

John R Clarke, Janet Johnston and Edward D Finley
Annals of surgery, v 246(3), pp 395-405
Sep 2007
DOI: https://doi.org/10.1097/SLA.0b013e3181469987
PMID: 17717443
Featured in Collection :   UN Sustainable Development Goals @ Drexel
url
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354View
Accepted (AM)Open Access (License Unspecified),  Open

Abstract

Humans Medical Errors - statistics & numerical data Pennsylvania - epidemiology Risk Factors Risk Management Safety Management Surgical Procedures, Operative
We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part). We examined all reports from all hospitals and ambulatory surgical centers--in a state that requires reporting of wrong-site surgery--from the initiation of the reporting requirement in June 2004 through December 2006. Over 30 months, there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient (34), wrong procedure (39), wrong side (298), and/or wrong part (60); 83 patients had incorrect procedures done to completion. Procedures on the lower extremities were the most common (30%). Common contributions to errors resulting in the initiation of wrong-site surgery involved patient positioning (20) and anesthesia interventions (29) before any planned time-out process, not verifying consents (22) or site markings (16), and not doing a proper time-out process (17). Actions involving operating surgeons contributed to 92. Common sources of successful recovery to prevent wrong-site surgery were patients (57), circulating nurses (30), and verifying consents (43). Interestingly, 31 formal time-out processes were unsuccessful in preventing "wrong" surgery. Wrong-site surgery continues to occur regularly, especially wrong-side surgery, even with formal site verification. Many errors occur before the time-out; some persist despite the verification protocol. Patients and nurses are the surgeons' best allies. Verification, starting with verification of the consent, needs to occur at multiple points before the incision.

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7 Record Views
89 citations in Web of Science
118 citations in Scopus

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UN Sustainable Development Goals (SDGs)

This publication has contributed to the advancement of the following goals:

#3 Good Health and Well-Being
#4 Quality Education

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Web of Science research areas
Surgery
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