Communication errors, lack of time-out linked to wrong-person/wrong-site procedures
TUESDAY, Oct. 19 (HealthDay News) -- Wrong-patient and wrong-site procedures -- which are surgical "never events" -- may be continuing at a high frequency, according to research published in the October issue of the Archives of Surgery.
Philip F. Stahel, M.D., of the Denver Health Medical Center, and colleagues analyzed data from a physician insurance database covering Colorado physicians, which contained 27,370 physician-reported adverse occurrences from 2002 to 2008.
The researchers found 25 wrong-patient and 107 wrong-site procedures. Significant harm occurred in five wrong-patient procedures and 38 wrong-site procedures, with one patient dying after a wrong-site procedure, which was a wrong-sided placement of a chest tube. The main root causes behind wrong-patient procedures were errors in diagnosis (56 percent) and communication errors (all cases). Wrong-site events were linked to errors in judgment (85 percent) and failure to perform a "time-out" beforehand (72 percent). Non-surgical specialties and surgical disciplines contributed equally to adverse outcomes related to wrong-site events.
"Inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome. On the basis of these findings, a strict adherence to the Universal Protocol must be expanded to non-surgical specialties to achieve a zero-tolerance philosophy for these preventable incidents," the authors conclude.
Several co-authors disclosed relationships with the Colorado Physician Insurance Company, the database used in the study.
Abstract
Full Text (subscription or payment may be required)
Editorial (subscription or payment may be required)