Preventing Wrong Site Surgery – A Quarterly Update From The Pennsylvania Patient Safety Authority (PSA)

Of particular interest is that the number of reports for wrong site surgery in Pennsylvania appear to be declining.  However, wrong site placement of local anesthetic blocks is becoming an increasing percentage of the reports.  For example wrong site blocks constituted 20% of the wrong site events in the first six months of data reporting to the PSA, but they accounted for 44% of wrong site events in the most recent six months of reporting.  These are two of the four examples provided by the PSA: 1) a patient was scheduled for a surgical procedure on the left hand under axillary block. The anesthesiologist blocked the right arm. The correct arm, left, was marked appropriately. The error was discovered by the anesthesiologist after initiating the block.  2) A patient was admitted for surgery [on the right knee]. The patient was seen by the anesthesiologist who asked the patient which knee was to be operated on. The patient stated “left.” The anesthesiologist performed the nerve block on the left side. The patient was taken to the OR for the right-knee surgery where it was determined the nerve block was done on the wrong side.  Doing a formal time-out before an anesthetic block could potentially eliminate about 27% (92 of 337) of the wrong site errors reported in the surgical suite. However, based on the data from the Preventing Wrong-Site Surgery Project, a time-out before an anesthetic block does not eliminate the need to do a time-out just before the start of the surgical procedure, with the site marking visible in the prepped and draped surgical field.

In the opinion of the PSA, the 2010 revision of the Joint Commission’s Universal Protocol does not help the confusion about when to do the time-out.  The 2009 version states that the time-out should be done before the start of anesthesia; the 2010 version reverts to stating that the time-out should be done before the incision.  Based on multiple studies from the Preventing Wrong-Site Surgery Project, the Authority strongly advises that a formal time-out be done with the anesthesia provider just before any anesthetic block is placed and that another time-out be done with the surgeon just before the incision, unless the surgeon performs the anesthetic block and incision in continuity after the surgical field has been prepped and draped. 

Ref: Pennsylvania Patient Safety Advisory 2008;6:141-143

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

Comments

[surgical error]

A surgical error compensation claim falls within the category of medical negligence and not as a personal injury. A surgical error compensation claim is based on the evidence that the surgeon has made an error which was avoidable had the surgeon paid due care and attention, and that you – as the patient – have suffered an injury because of it. That injury must also lead to damages on your part – either prolonged physical or psychological trauma, the inability to work with subsequent loss of earnings, or some other expense which now justifies a surgical error compensation claim.

[Surgical Error Compensation Claims]

As with all medical negligence claims, if you have been injured due to a surgical error you have a three year period within which your claim must be made. This three year period would normally begin on the date of your surgery. However, in some circumstances you may not be aware that a problem has occurred until a later date. In these cases the three year period would not begin on the date of your surgery, but the date you became aware of the error and injury.

[surgical error compensation]

The Health and Safety Executive prefers not to disclose the number of surgical error claims for compensation that are made each year in Ireland, and it is only when we read about them in the newspapers that we find out the sort of surgical errors that are made due to a lack of care in Irish hospitals.

[surgical errors]

Whenever a patient requires a surgical procedure, they will be informed about any risks associated with having an operation, but they cannot be expected to anticipate surgical errors. Surgical patients place their trust in the surgeon and medical team supporting him, and reasonably believe that they are competent, experienced and prudent.

[Keystone East Insurance]

Seems like the "time out" will eliminate a lot of mistakes. Knee surgery is one thing but imagine if the surgery was on a vital organ.

[Penyakit Diabetes]

These are two of the four examples provided by the PSA: 1) a patient was scheduled for a surgical procedure on the left hand under axillary block. The anesthesiologist blocked the right arm. The correct arm, left, was marked appropriately. The error was discovered by the anesthesiologist after initiating the block. 2) A patient was admitted for surgery [on the right knee].