Wrong sided surgery in the Commonwealth of Pennsylvania

*Wrong sided surgery continues as a problem in the State of Pennsylvania. According to the Patient Safety Authority* (June, 2007 press release) the data show “every other day in Pennsylvania healthcare facilities an actual adverse event or near miss of wrong-site surgery occurs... In a 30-month time period (June 2004-December 2006) the Authority received reports of 427 near misses and serious events of wrong site surgery...Of the events that reached the patient in the operating room, 69% were wrong sided surgeries, 14% were wrong body part surgeries, 9% were wrong procedure and 8% were wrong patient…Orthopedic and ophthalmologic procedures were the most common for wrong-site surgeries.” The risk factors for wrong site surgeries included: “multiple procedures and or multiple surgeons, communication breakdowns, time pressures, incomplete preoperative assessments, and organizational cultural factors that are not conducive to promoting teamwork such as an attitude that surgeon’s decisions should never be questioned.” In many cases the patient or the family was the key factor in preventing the wrong site surgery from occurring (see Patient Safety Advisory Newsletter June 2007 for a very detailed discussion of this problem   http://www.psa.state.pa.us/psa/lib/psa/advisories/v4n2_june_2007/jun_2007_v4_n2_article_wrong-site_surgery.pdf ).

The Patient Safety Authority is an independent state agency charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety.  Their web site is very good and their newsletters very helpful.

David S. Smith, M.D., Ph.D.