Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable?

Authors:
Dr Paul Barach, BSc, MD, MPH
Dr Paul Barach, BSc, MD, MPH
Wayne State University School of Medicine
Clinical Professor
Anesthesia, critical care
Chicago, IL | United States

Arch Surg 2006 Sep;141(9):931-9

Department of Pediatrics, The University of Chicago Comer Children's Hospital, Chicago, IL 60637, USA.

Hypothesis: Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) are devastating, unacceptable, and often result in litigation, but their frequency and root causes are unknown. Wrong-side/wrong-site, wrong-procedure, and wrong-patient events are likely more common than realized, with little evidence that current prevention practice is adequate.

Design: Analysis of several databases demonstrates that WSPEs occur across all specialties, with high numbers noted in orthopedic and dental surgery. Databases analyzed included: (1) the National Practitioner Data Bank (NPDB), (2) the Florida Code 15 mandatory reporting system, (3) the American Society of Anesthesiologists (ASA) Closed Claims Project database, and (4) a novel Web-based system for collecting WSPE cases (http://www.wrong-side.org).

Results: The NPDB recorded 5940 WSPEs (2217 wrong-side surgical procedures and 3723 wrong-treatment/wrong-procedure errors) in 13 years. Florida Code 15 occurrences of WSPEs number 494 since 1991, averaging 75 events per year since 2000. The ASA Closed Claims Project has recorded 54 cases of WSPEs. Analysis of WSPE cases, including WSPE cases submitted to http://www.wrong-side.org, suggest several common causes of WSPEs and recurrent systemic failures. Based on these findings, we estimate that there are 1300 to 2700 WSPEs annually in the United States. Despite a significant number of cases, reporting of WSPEs is virtually nonexistent, with reports in the lay press far more common than reports in the medical literature. Our research suggests clear factors that contribute to the occurrence of WSPEs, as well as ways to reduce them.

Conclusions: Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events, although rare, are more common than health care providers and patients appreciate. Prevention of WSPEs requires new and innovative technologies, reporting of case occurrence, and learning from successful safety initiatives (such as in transfusion medicine and other high-risk nonmedical industries), while reducing the shame associated with these events.

Download full-text PDF

Source
http://dx.doi.org/10.1001/archsurg.141.9.931DOI Listing
September 2006
32 Reads
34 Citations
4.930 Impact Factor

Article Mentions


Provided by Crossref Event Data
f1000
F1000: F1000
July 2, 2008, 8:00 pm EST

Publication Analysis

Top Keywords

wrong-procedure wrong-patient
16
wrong-side/wrong-site wrong-procedure
16
wrong-patient adverse
12
wspe cases
12
adverse events
12
wspes
10
asa closed
8
claims project
8
florida code
8
closed claims
8
events
6
cases
5
occurrences wspes
4
code occurrences
4
wrong-side/wrong-site
4
wrong-treatment/wrong-procedure errors
4
3723 wrong-treatment/wrong-procedure
4
health care
4
wspes number
4
common health
4

Similar Publications