Page 59 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

Safety Authority indicated that 60 wrong-site surgeries were

reported from mid-2016 to mid-2017; nerve blocks
administered to the wrong side represented nearly one-fourth

of these events. A 2018 study assessing surgical adverse
8
events and near misses at 86 Veterans Health Administration
facilities found that, although overall surgical adverse event

rates had decreased from 1.74 to .47 per 100,000 procedures
over seven years, there were still 90 wrong-side procedures, 65

wrong-site procedures, and 14 wrong procedures reported.
9
Moreover, almost 30 percent of these adverse events could be
attributed to an incomplete or incorrectly performed surgical

timeout. These data underscore the need for continued
10
efforts in thoughtfully and thoroughly conducting surgical time

outs. In 2003, the Joint Commission made the elimination of
11
wrong-site surgeries a National Patient Safety Goal, and the
following year required compliance with a Universal Protocol.
12
The Universal Protocol requires three separate steps:

 the proper preoperative identification of the patient by the
three members of the team (surgeon, anesthesiologist,

and nurse)

 marking of the operative site, and

8 Arnold TV. Update on wrong-site surgery: more data provides more insight. Pa Patient Saf Advis. 2018; 15(1).
http://patientsafety.pa.gov/ADVISORIES/Pages/201803_WSSUpdate.aspx
9 Neily J, Soncrant C, Mills PD, et al. Assessment of incorrect surgical procedures within and outside the
operating room: a follow-up study from US Veterans Health Administration Medical Centers. JAMA Netw Open.
2018; 1(7): e185147.
10 Id.
11 https://aornjournal.onlinelibrary.wiley.com/doi/full/10.1002/aorn.12731
12 Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg. 2007;246:395-405

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