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Wrong-Site Surgeries Remain Problem Despite Precautions

March 7, 2008
Written by: , Filed in: Practice Management
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In Minnesota, the surgical error of wrong-site surgeries continues to be a
problem despite adoption of the Universal Protocol and State reporting
requirements for this serious error.

Background:
Surgical errors are typically the easiest to understand of the 28 ‘never
events’ (serious preventable medical errors) listed by the National Quality
Forum (NQF). Many preventive guidelines have been published in an attempt to
reduce these surgical ‘never events.’

Objective:
To describe the Minnesota experience since 2003 with the NQF’s ‘never events’
list.

In Minnesota, the surgical error of wrong-site surgeries continues to be a problem despite adoption of the Universal Protocol and State reporting requirements for this serious error. Background: Surgical errors are typically the easiest to understand of the 28 'never events' (serious preventable medical errors) listed by the National Quality Forum (NQF). Many preventive guidelines have been published in an attempt to reduce these surgical 'never events.' Objective: To describe the Minnesota experience since 2003 with the NQF's 'never events' list. [text_ad] Results: The Minnesota legislature passed the Adverse Health Care Event Reporting Act, and hospitals were required to report the different 'never events' to the Minnesota authorities. With respect to surgical 'never events,' hospitals had to report surgical errors, including surgery on the wrong patient, surgery on the wrong body part, the wrong procedure, foreign body retention, or the intraoperative or immediately postoperative death of a healthy patient (ASA Class 1). From July 2003 to October 2004, these hospitals reported performing 356,000 surgical procedures, during which the following surgical 'never events' occurred: 31 retained foreign bodies, 13 wrong-site procedures, 5 wrong procedures, 2 deaths of healthy individuals, and 1 surgery on the wrong patient. However, from October 2004 to October 2005, the surgical error list included 26 wrong-site procedures. From October 2005 to October 2006, 31 wrong-site procedures were reported. Reviewer's Comments: Despite the emphasis on preventing these surgical errors, the adoption of the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery, and the reporting requirements, these errors continue to be an issue and a problem. Whenever people are involved in a process, the potential exists for human error. Because people are involved, you must incorporate redundancies and several steps in an attempt to prevent these different surgical 'never events' in your practice. Reviewer: Richard P. Kidwell, JD Reference: West JC: ASHRM Journal; 2006;26 (1): 15-21 Surgical 'Never Events': How Common Are Adverse Occurrences? [text_ad]

Results:
The Minnesota legislature passed the Adverse Health Care Event Reporting Act,
and hospitals were required to report the different ‘never events’ to the
Minnesota authorities. With respect to surgical ‘never events,’ hospitals had
to report surgical errors, including surgery on the wrong patient, surgery on
the wrong body part, the wrong procedure, foreign body retention, or the
intraoperative or immediately postoperative death of a healthy patient (ASA
Class 1).

From July 2003 to October 2004, these hospitals reported performing 356,000
surgical procedures, during which the following surgical ‘never events’
occurred: 31 retained foreign bodies, 13 wrong-site procedures, 5 wrong
procedures, 2 deaths of healthy individuals, and 1 surgery on the wrong
patient. However, from October 2004 to October 2005, the surgical error list
included 26 wrong-site procedures. From October 2005 to October 2006, 31
wrong-site procedures were reported.

Reviewer’s Comments:
Despite the emphasis on preventing these surgical errors, the adoption of the
Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person
Surgery, and the reporting requirements, these errors continue to be an issue
and a problem.

Whenever people are involved in a process, the potential exists for human
error. Because people are involved, you must incorporate redundancies and
several steps in an attempt to prevent these different surgical ‘never events’
in your practice.

Reviewer: Richard P. Kidwell, JD

Reference:
West JC: ASHRM Journal; 2006;26 (1): 15-21 Surgical ‘Never Events’: How
Common Are Adverse Occurrences?

In Minnesota, the surgical error of wrong-site surgeries continues to be a problem despite adoption of the Universal Protocol and State reporting requirements for this serious error. Background: Surgical errors are typically the easiest to understand of the 28 'never events' (serious preventable medical errors) listed by the National Quality Forum (NQF). Many preventive guidelines have been published in an attempt to reduce these surgical 'never events.' Objective: To describe the Minnesota experience since 2003 with the NQF's 'never events' list. [text_ad] Results: The Minnesota legislature passed the Adverse Health Care Event Reporting Act, and hospitals were required to report the different 'never events' to the Minnesota authorities. With respect to surgical 'never events,' hospitals had to report surgical errors, including surgery on the wrong patient, surgery on the wrong body part, the wrong procedure, foreign body retention, or the intraoperative or immediately postoperative death of a healthy patient (ASA Class 1). From July 2003 to October 2004, these hospitals reported performing 356,000 surgical procedures, during which the following surgical 'never events' occurred: 31 retained foreign bodies, 13 wrong-site procedures, 5 wrong procedures, 2 deaths of healthy individuals, and 1 surgery on the wrong patient. However, from October 2004 to October 2005, the surgical error list included 26 wrong-site procedures. From October 2005 to October 2006, 31 wrong-site procedures were reported. Reviewer's Comments: Despite the emphasis on preventing these surgical errors, the adoption of the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery, and the reporting requirements, these errors continue to be an issue and a problem. Whenever people are involved in a process, the potential exists for human error. Because people are involved, you must incorporate redundancies and several steps in an attempt to prevent these different surgical 'never events' in your practice. Reviewer: Richard P. Kidwell, JD Reference: West JC: ASHRM Journal; 2006;26 (1): 15-21 Surgical 'Never Events': How Common Are Adverse Occurrences? [text_ad]
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