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Single or Multiple Incident: Multiple
Date: 3/1/2018 12:00:00 AM

This alert provides an overview of wrong site surgeries over the period of July 2004 to September 2017 as well as a focused analysis of the events reported between October 2016 and September 2017. The three most common types of wrong-site procedures reported through PA-PSRS since July 2004 have remained consistent and continue to account for about 50% of all wrong-site surgery events: • Perioperative nerve blocks administered by anesthesiologists and surgeons (25.7%) • Spinal procedures (e.g., wrong level; 12.5%) • Pain-management procedures (12.2%) The most notable change was in the percentage of wrong-site pain-management procedures, which increased 7% from the last update. The most common clinical specialties for which a wrong-site event was reported during the one-year period were pain management (21.7%), anesthesia (15.0%), and ophthalmology (15.0%). Wrong-site nerve blocks accounted for nearly one-quarter (23.3%) of the events reported in this 12-month period. The most improvement was noted in the number of wrong-site spinal procedures reported in the one-year period (6.7%). The twelve months represented in the update (i.e., October 2016 through September 2017) show an upward trend in the number of wrong-site surgery events reported. The most common wrong-site procedures include nerve blocks and spinal injections for pain management.

Update on Wrong-Site Surgery: More Data Provides More Insight