Difference Between Near Miss, Wrong-Site Surgery Studied

Near misses more likely to involve surgical team members who feel able to express concerns
By Andrea Mongler
HealthDay Reporter

MONDAY, Aug. 17 (HealthDay News) -- There are important differences between errors that are caught as near misses and those that progress to wrong-site surgery, and health care professionals can follow simple steps to reduce or eliminate wrong-site surgery, according to a study in the August issue of the AORN Journal.

Mary Blanco, R.N., of the Pennsylvania Safety Authority in Harrisburg, and colleagues had staff members in facilities across Pennsylvania analyze 97 wrong-site surgery near misses and 44 actual wrong-site surgeries from August 2007 to August 2008.

The researchers found that, of the near misses, four involved drops in the wrong eye, four involved skin preparation at the wrong site, and one involved general instead of regional anesthesia. Of the actual wrong-site surgeries, 13 involved anesthesia in the wrong location, six involved other injections, one involved a laser procedure in the eye, and 24 involved an incision. The near misses were more likely to involve compliance with patient identification and preoperative reconciliation protocols, accurate scheduling, notation on the consent form of the surgical site, surgeon participation in preoperative verification, time outs performed with all surgical team members involved and with the site marking visible, and encouragement of team members to speak up if concerned.

"The most significant differences between reports of near misses and actual wrong-site occurrences related to empowerment, suggesting that the time out script should contain an explicit statement telling members of the operating room team to speak up if they have concerns," the authors write.

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