Literature DB >> 17074875

Experience of wrong site surgery and surgical marking practices among clinicians in the UK.

Sally J Giles1, Penny Rhodes, Gill Clements, Gary A Cook, Ruth Hayton, Melanie J Maxwell, Trevor A Sheldon, John Wright.   

Abstract

BACKGROUND: Little is known about the incidence of "wrong site surgery", but the consequences of this type of medical error can be severe. Guidance from both the USA and more recently the UK has highlighted the importance of preventing error by marking patients before surgery.
OBJECTIVE: To investigate the experiences of wrong site surgery and current marking practices among clinicians in the UK before the release of a national Correct Site Surgery Alert.
METHODS: 38 telephone or face-to-face interviews were conducted with consultant surgeons in ophthalmology, orthopaedics and urology in 14 National Health Service hospitals in the UK. The interviews were coded and analysed thematically using the software package QSR Nud*ist 6.
RESULTS: Most surgeons had experience of wrong site surgery, but there was no clear pattern of underlying causes. Marking practices varied considerably. Surgeons were divided on the value of marking and varied in their practices. Orthopaedic surgeons reported that they marked before surgery; however, some urologists and ophthalmologists reported that they did not. There seemed to be no formal hospital policies in place specifically relating to wrong site surgery, and there were problems associated with implementing a system of marking in some cases. The methods used to mark patients also varied. Some surgeons believed that marking was a limited method of preventing wrong site surgery and may even increase the risk of wrong site surgery.
CONCLUSION: Marking practices are variable and marking is not always used. Introducing standard guidance on marking may reduce the overall risk of wrong site surgery, especially as clinicians work at different hospital sites. However, the more specific needs of people and specialties must also be considered.

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Year:  2006        PMID: 17074875      PMCID: PMC2565824          DOI: 10.1136/qshc.2006.018333

Source DB:  PubMed          Journal:  Qual Saf Health Care        ISSN: 1475-3898


  7 in total

1.  Reasons for not reporting adverse incidents: an empirical study.

Authors:  C Vincent; N Stanhope; M Crowley-Murphy
Journal:  J Eval Clin Pract       Date:  1999-02       Impact factor: 2.431

2.  Personal knowledge.

Authors:  Kieran Sweeney
Journal:  BMJ       Date:  2006-01-21

3.  Quality in Australian Health Care Study.

Authors:  R M Wilson; W B Runciman; R W Gibberd; B T Harrison; J D Hamilton
Journal:  Med J Aust       Date:  1996-06-17       Impact factor: 7.738

4.  The culture of safety: results of an organization-wide survey in 15 California hospitals.

Authors:  S J Singer; D M Gaba; J J Geppert; A D Sinaiko; S K Howard; K C Park
Journal:  Qual Saf Health Care       Date:  2003-04

5.  The incidence and nature of surgical adverse events in Colorado and Utah in 1992.

Authors:  A A Gawande; E J Thomas; M J Zinner; T A Brennan
Journal:  Surgery       Date:  1999-07       Impact factor: 3.982

6.  Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

Authors:  T A Brennan; L L Leape; N M Laird; L Hebert; A R Localio; A G Lawthers; J P Newhouse; P C Weiler; H H Hiatt
Journal:  N Engl J Med       Date:  1991-02-07       Impact factor: 91.245

7.  The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.

Authors:  G Ross Baker; Peter G Norton; Virginia Flintoft; Régis Blais; Adalsteinn Brown; Jafna Cox; Ed Etchells; William A Ghali; Philip Hébert; Sumit R Majumdar; Maeve O'Beirne; Luz Palacios-Derflingher; Robert J Reid; Sam Sheps; Robyn Tamblyn
Journal:  CMAJ       Date:  2004-05-25       Impact factor: 8.262

  7 in total
  11 in total

1.  An unusual occurrence in surgical site marking.

Authors:  Geraint Williams; Andy Roche; Michael Hennessy; John Gannon
Journal:  Ann R Coll Surg Engl       Date:  2009-03       Impact factor: 1.891

2.  Wrong site surgery-where are we and what is the next step?

Authors:  Tyson K Cobb
Journal:  Hand (N Y)       Date:  2012-06

Review 3.  Interventions for reducing wrong-site surgery and invasive clinical procedures.

Authors:  Catherine M Algie; Robert K Mahar; Jason Wasiak; Lachlan Batty; Russell L Gruen; Patrick D Mahar
Journal:  Cochrane Database Syst Rev       Date:  2015-03-30

Review 4.  [Wrong site surgery : Incidence, risk factors and prevention].

Authors:  P C Ambe; B Sommer; H Zirngibl
Journal:  Chirurg       Date:  2015-11       Impact factor: 0.955

5.  Surgery Is in Itself a Risk Factor for the Patient.

Authors:  Verónica Aranaz-Ostáriz; María Teresa Gea-Velázquez De Castro; Francisco López-Rodríguez-Arias; Diego San José-Saras; Jorge Vicente-Guijarro; Alberto Pardo-Hernández; Jesús María Aranaz-Andrés
Journal:  Int J Environ Res Public Health       Date:  2022-04-14       Impact factor: 4.614

6.  Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics?--Can the checklist help? Supporting evidence from analysis of a national patient incident reporting system.

Authors:  Sukhmeet S Panesar; Douglas J Noble; Saqeb B Mirza; Bhavesh Patel; Bhupinder Mann; Mark Emerton; Kevin Cleary; Aziz Sheikh; Mohit Bhandari
Journal:  J Orthop Surg Res       Date:  2011-04-18       Impact factor: 2.359

Review 7.  Current issues in patient safety in surgery: a review.

Authors:  Fernando J Kim; Rodrigo Donalisio da Silva; Diedra Gustafson; Leticia Nogueira; Timothy Harlin; David L Paul
Journal:  Patient Saf Surg       Date:  2015-06-05

8.  Sentinel events in ophthalmology: experience from Hong Kong.

Authors:  Shiu Ting Mak
Journal:  J Ophthalmol       Date:  2015-03-02       Impact factor: 1.909

9.  Risk Analysis for Patient Safety in Surgical Departments: Cross-Sectional Design Usefulness.

Authors:  Verónica Aranaz Ostáriz; María Teresa Gea Velázquez de Castro; Francisco López Rodríguez-Arias; José Lorenzo Valencia Martín; Carlos Aibar Remón; Juana Requena Puche; Cristina Díaz-Agero Pérez; Antonio Fernando Compañ Rosique; Jesús María Aranaz Andrés
Journal:  Int J Environ Res Public Health       Date:  2020-04-07       Impact factor: 3.390

10.  Improving the preoperative care of patients with femoral neck fractures through the development and implementation of a checklist.

Authors:  Riaz Agha; Eric Edison; Alexander Fowler
Journal:  BMJ Qual Improv Rep       Date:  2014-03-05
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