Patient safety

Selected bibliography supporting the ten essential objectives for safe surgery

1. The team will operate on the correct patient at the correct site.

American Academy of Orthopaedic Surgery. "AAOS Advisory Statement on Wrong-Site Surgery." Retrieved 25 January, 2008, from http://www.aaos.org/about/papers/advistmt/1015.asp.

American College of Surgeons (2002). "Statement on ensuring correct patient, correct site, and correct procedure surgery." Bulletin of the American College of Surgeons 87(12).

Australian Commission on Safety and Quality in Healthcare. "Ensuring Correct Patient, Correct Site, Correct Procedure." Retrieved 23 August, 2007, from http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/former-pubs-archive-correct.

Joint Commission. "A follow-up review of wrong site surgery." Retrieved 3 May, 2007, from http://www.jointcommission.org/SentinelEvents/sentineleventalert/sea_24.htm.

Joint Commission. "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery." Retrieved 15 February, 2007, from http://www.jointcommission.org/PatientSafety/UniversalProtocol/.

Kwaan, M. R., D. M. Studdert, et al. (2006). "Incidence, patterns, and prevention of wrong-site surgery." Arch Surg 141(4): 353-7; discussion 357-8.

  • HYPOTHESIS: We hypothesized that wrong-site surgery is infrequent and that a substantial proportion of such incidents are not preventable by current site-verification protocols.
  • DESIGN: Case series and survey of site-verification protocols.
  • SETTING: Hospitals and a malpractice liability insurer.
  • PATIENTS AND OTHER PARTICIPANTS: All wrong-site surgery cases reported to a large malpractice insurer between 1985 and 2004.
  • MAIN OUTCOME MEASURES: Incidence, characteristics, and causes of wrong-site surgery and characteristics of site-verification protocols.
  • RESULTS: Among 2,826,367 operations at insured institutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112,994 operations (95% confidence interval, 1 in 76,336 to 1 in 174,825). Medical records were available for review in 13 cases. Among reviewed claims, patient injury was permanent-significant in 1, temporary-major in 2, and temporary-minor or temporary-insignificant in 10. Under optimal conditions, the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol might have prevented 8 (62%) of 13 cases. Hospital protocol design varied significantly. The protocols mandated 2 to 4 personnel to perform 12 separate operative-site checks on average (range, 5-20). Five protocols required site marking in cases that involved nonmidline organs or structures; 6 required it in all cases.
  • CONCLUSIONS: Wrong-site surgery is unacceptable but exceedingly rare, and major injury from wrong-site surgery is even rarer. Current site-verification protocols could have prevented only two thirds of the examined cases. Many protocols involve considerable complexity without clear added benefit.

National Patient Safety Agency. "Correct Site Surgery - Making your surgery safer." Retrieved 3 May, 2007, from http://www.npsa.nhs.uk/site/media/documents/884_0186FEB05_01_26.pdf.

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