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Topic: Surgery
Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 5/11/2012 12:00:00 AM
Country: United States of America
Organization: Minnesota Hospital Association (USA)

This alert discusses patient safety incidents of wrong surgeries or wrong procedures. Close to 40% of wrong surgeries/procedures reported under the Minnesota Adverse Event Reporting Law last year (October 7, 2010-October 6, 2011) were related to wrong implants. Review of reported wrong procedure events involving implants indicated issues with verification of the correct implant at each step of the process including: •Scheduling •Requesting the implant(s) •Pulling the implant(s) prior to case •Team Briefing •Pre-procedure verification •Time Out •Selecting implant(s) from case cart The recommendations to prevent similar patient safety incidents include verifications steps for: 1. Intraocular implants (IOL) 2. Other implants — when implant is known prior to the case 3. Other implants — when implant is not known prior to the case, e.g. hip or knee replacements.

Additional Details

Device:
intraocular lens (IOL), implants


Implant Verification