OBJECTIVE: To determine the frequency, root cause, and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol. DESIGN: Analysis of a prospective physician insurance database performed from January 1, 2002, to June 1, 2008. Deidentified cases were screened using predefined taxonomy filters, and data were analyzed by evaluation criteria defined a priori. SETTING: Colorado. PATIENTS: Database contained 27 370 physician self-reported adverse occurrences. MAIN OUTCOME MEASURES: Descriptive statistics were generated to examine the characteristics of the reporting physicians, the number of adverse events reported per year, and the root causes and occurrence-related patient outcomes. RESULTS: A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a "time-out" (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences. CONCLUSIONS: These data reveal a persisting high frequency of surgical "never events." Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.
OBJECTIVE: To determine the frequency, root cause, and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol. DESIGN: Analysis of a prospective physician insurance database performed from January 1, 2002, to June 1, 2008. Deidentified cases were screened using predefined taxonomy filters, and data were analyzed by evaluation criteria defined a priori. SETTING: Colorado. PATIENTS: Database contained 27 370 physician self-reported adverse occurrences. MAIN OUTCOME MEASURES: Descriptive statistics were generated to examine the characteristics of the reporting physicians, the number of adverse events reported per year, and the root causes and occurrence-related patient outcomes. RESULTS: A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a "time-out" (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences. CONCLUSIONS: These data reveal a persisting high frequency of surgical "never events." Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.
Authors: Cornelius A Thiels; Tarun Mohan Lal; Joseph M Nienow; Kalyan S Pasupathy; Renaldo C Blocker; Johnathon M Aho; Timothy I Morgenthaler; Robert R Cima; Susan Hallbeck; Juliane Bingener Journal: Surgery Date: 2015-05-29 Impact factor: 3.982
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
Authors: Scott E Sheehan; Nasia Safdar; Hardeep Singh; Dean F Sittig; Michael A Bruno; Kelli Keller; Samantha Kinnard; Michael C Brunner Journal: Appl Clin Inform Date: 2020-01-29 Impact factor: 2.342
Authors: Zachary A Abecassis; Lisa M McElroy; Ronak M Patel; Rebeca Khorzad; Charles Carroll; Sanjay Mehrotra Journal: J Surg Res Date: 2014-09-06 Impact factor: 2.192