American Surgical Association
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Getting Surgery Right
John R Clarke1, Janet Johnston*2, Edward D. Finley*2
1Drexel University, Wynnewood, PA;2ECRI, Plymouth Meeting, PA

OBJECTIVE(S): We sought to identify factors contributing to “wrong” surgery (wrong patient, procedure, side, or site).
METHODS: We examined all reports from all hospitals and ambulatory surgical centers -- in a state that requires reporting of surgery that involves the wrong patient, procedure, side, or site -- from the initiation of the reporting requirement in June 2004 until November 2006.
RESULTS: Over 28 months, there were 412 reports of near misses (249) or surgical interventions started (163) involving the wrong patient (31), wrong procedure (38), wrong side (286), and/or wrong site (57); 79 patients had “wrong” procedures done to completion. Procedures on the lower extremity were the most common (20%).
The most common sources or causes of errors resulting in the initiation of “wrong” surgery involved patient positioning (19) and regional anesthesia (28) prior to the site verification, not verifying consents (20) or site markings (15), and omitting formal site verifications (16). Actions involving operating surgeons contributed to 90.
The most common sources of successful recovery to prevent “wrong” surgery were patients (49), circulating nurses (37), and verifying consents (40). Interestingly, 31 formal site verifications were unsuccessful in preventing “wrong” surgery.
CONCLUSIONS: “Wrong” surgery continues to occur regularly, especially wrong-side surgery, even with formal site verifications. Many errors occur before the site verification; some persist despite site verification. Patients and nurses are the surgeons’ best allies. Verification, starting with verification of the consent, needs to occur at multiple points prior to the incision.

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