Wrong-site orthopedic operations on the extremities: the Pennsylvania experience
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Clarke, John R., author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, June 2015
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Medical Errors -- statistics & numerical data Orthopedic Procedures -- statistics & numerical data Surgical Procedures, Operative -- statistics & numerical data Extremities -- surgery Patient Safety Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- The Pennsylvania Patient Safety Authority analyzed 83 wrong-site extremity procedures within the domain of orthopedic surgery reported over a nine-year period, representing 15% of the 541 reports of wrong-site operating room procedures in Pennsylvania hospitals and ambulatory surgical facilities from July 2004 through June 2013. The most common body parts involved were the hand (6% of all 541 reports), the knee (5%), and the foot (3%). All 34 wrong-site hand procedures were initiated at the wrong site on the correct hand; 12 involved operating on an adjacent finger, and 9 involved making an incision for a carpal tunnel release instead of an intended trigger finger release. Most (92%) of the 25 wrong-site knee procedures were performed on the wrong knee. The 14 wrong-site foot procedures were a mix of both the wrong foot and the wrong site on the correct foot. Overall, 18 wrong-site procedures on the legs involved the injection of local anesthetic into the knee joint or foot at the beginning of the procedure; 13 of them were done without the benefit of a proper time-out. The following marking and time-out practices might have prevented specific types of wrong-site extremity procedures: (1) mark the site close to the planned incision and reference it during all steps leading up to the incision, and (2) do separate time-outs for separate procedures on the same patient.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages 19-27)).
- NLM Unique ID:
- 101661151 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101661151