|Wrong Site Surgery||18574||3771||6/1/2017 6:00:00 AM||Surgery||Canada||Manitoba Health||This alert discusses a surgical patient safety incident of wrong site surgery as well as performance of an inadvertent additional surgical procedure. A patient consented to surgical release of their index trigger finger. The Time Out phase of the Safe Surgical Checklist was completed followed by the departure of a surgical team member from the operating room theatre. Upon the return of the team member to the operating theatre, the surgery commenced. An additional carpal tunnel surgery was inadvertently performed in addition to the planned index trigger finger surgery.
Contributing factors identified suboptimal implementation of the surgical safety check list as well as surgical marking procedures. Recommendations to prevent similar incidents are provided.||9/17/2019 3:59:47 PM||supplémentaire, emplacement incorrect, temps d'arrêt, marquage du site chirurgical ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Wrong Site Surgery||18551||3792||6/1/2018 6:00:00 AM||Surgery||Canada||Manitoba Health||This alert describes a patient safety incident of wrong site surgery where an additional surgery was performed in addition to that consented. A client consented to surgery for a trigger finger. The surgeon was not in the operating theatre while the team prepped, draped, and anesthetized the patient. The surgeon returned to the operating theatre and began the surgery. The Time Out phase of the Safe Surgical Checklist was not completed prior to the incision. A left carpal tunnel surgery was completed, in addition to the original consented surgery.
Contributing factors included an incomplete Time Out phase of the Safe Surgical Checklist and incorrect marking of the surgical site. Recommendations to prevent similar incidents are provided.||9/16/2019 8:23:34 PM||consentement, marquage chirurgical, temps d’arrêt, liste de vérification d’une chirurgie sécuritaire, doigt à ressort, tunnel carpien, marquage erroné, liste de contrôle de la ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Wrong surgery because of a wrong surgical site marking||18976||4107||12/16/2019 7:00:00 AM||Surgery||South Korea||Korea Patient Safety Reporting & Learning System||This alert describes patient safety incidents of surgery being performed on the wrong body part. Contributing factors were wrong surgical site marking, wrong check of the examination image (X-ray), and removal of a surgical marker before the procedure. Two cases are described. Recommendations focusing on surgical site marking and use of time out procedures are provided. Included in the alert are an example of an operating room performing a time out and guidelines for marking surgical sites.||3/1/2022 7:04:43 PM||soins de courte durée, intervention chirurgicale, anesthésie, médecine, médicament, soins mauvais site, mauvais examen de l’image radiologique, mauvaise partie du corps, temps d’ ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Wrong site surgery (right/left)||17805||3112||1/1/2011 7:00:00 AM||Surgery||Japan||Japan Council for Quality Health Care||This alert discusses patient safety incidents where the wrong site was operated on. Twenty one cases were reported between January 1, 2007 and November 30, 2010. In the 21 cases, marking of the site occurred five times. However, among the five cases with marking, two cases were a marking mix-up due to right-left confusion, in one case the marking came off, and in two cases the marking was not clearly seen due to being covered by cloth, etc. The contributing factors to the wrong site surgery cases were as follows:
1) Marking of the surgical site was not properly carried out.
2) Marking was carried out but the surgical site was not confirmed immediately before making the skin incision.
One case is described. On the day before surgery for an inguinal hernia on the left side inguinal region, the surgical site was confirmed by the physician, the patient and family, and marked on the dorsum of foot with a permanent marker. On the day of surgery, the primary physician confirmed the patient’s surgery site, etc., and signed the checklist in the operation room. The anesthesiologist and the operation room nurse then confirmed the surgical site of the patient, etc., together, and signed the checklist. After initiating anesthesia, the primary physician confirmed the marking on the left dorsum of foot, which was the side for the surgery. But upon examination of the inguinal region, he/she noticed a swelling on the right inguinal region. The primary physician performed skin disinfection, saying “the surgical site, left,” but located the right inguinal region as the surgical field. The marking was not confirmed immediately before making the skin incision.
Recommendations to prevent this type of incident are provided.||7/22/2015 5:51:38 PM||Liste de vérification, délai d’attente, site chirurgical, marquage ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist|
|Wrong-Site Surgery Protocol Followed||17754||171||12/1/2012 7:00:00 AM||Surgery||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert identified the patient safety incidents of wrong site surgey avoided due to compliance with the Universal protocol, the implementation of multiple checks of the surgical consent, surgical markings, and communication among staff, patients, and family members. Three examples are provided:
- The procedure on the operating room schedule was listed as left cataract extraction. All of the patient’s paperwork, history and physical, operation consent, physician’s orders, and patient preregistration form all state right cataract extraction. The incorrect side [on the schedule] was noted during verbal verification of the side during the registration process with the patient. The correct side, right, was then verified with the patient and the surgeon.
- A surgical permit on [the patient’s] chart . . . [was] signed by the mother of another patient. The permit should have said one eye; this [consent indicated] both eyes. The [staff] noted the wrong parental signature. Another [correct surgical] permit was obtained from the parents.
- The operating room manager schedule stated a right-side hernia repair. All documentation, [including the] consent, [indicated] the left [side]. The surgeon marked the right side in error. A registered nurse handoff communication identified the error.||7/22/2015 5:51:10 PM||de transfert, membres de la famille, protocole universel, marquage du site opératoire ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist|
|Wrong site surgery (right/left)||19540||JP008||7/1/2007 6:00:00 AM||Surgery||Japan||Japan Council for Quality Health Care||This alert discusses wrong site surgery patient safety incidents. Nine cases were reported from October 1, 2004 to December 31, 2006. Two cases involved surgical marking; one case was a marking mix-up due to right-left confusion and another case was marked on the left hand to identify side of surgery for ophthalmic surgery but surgery was commenced on the right eye. Most of the cases due to right-left confusion were caused by markings on the surgical site not properly carried out.
Two cases are described in detail. In one case of bilateral osteoarthritis of the knees, surgery on left knee had more severe
symptoms was firstly scheduled. On the day before surgery, the patient was given an explanation of the surgery to be performed on the left knee but the knee was not marked as instructed in a manual. The following day in the OR the nurses, the anesthesiologist, and the surgeon confirmed with the patient that surgery was to be performed on the left knee, but did not confirm the marking at that time. Under general anesthesia, the surgeon did preoperative preparation on the right knee, contrary to the planned left knee, and the surgery began without anyone noticing the mistake. Thirty minutes after the surgery began, the mix-up between left and right was noticed.||7/22/2015 5:53:05 PM||patients hospitalisés, patients externes, soins ambulatoires méprise sur la gauche-droite, marquage, chirurgie du genou, vitrectomie, anesthésie générale ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist|
|Snapshot: Quarterly Update on Wrong-Site Surgery||18183||3475||6/1/2015 6:00:00 AM||Surgery||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert provides an update on the on-going reporting of wrong-site surgical procedures collected by the Pennsylvania Patient Safety Authority.
There were 14 reports of wrong-site surgery in Pennsylvania operating rooms (ORs) during the first quarter of 2015. This number represents a continued regression in the 2014-2015 academic year despite progress in the first quarter of the academic year. Half of the reported events involved injections or spinal procedures (50%, n = 7): two wrong-side paravertebral pain blocks, one intra-articular pain injection, one wrong-side preoperative regional block by an anesthesia provider, one unconsented local anesthetic injection by a surgeon despite a formal time-out, and two wrong-level spinal procedures.
Confirmation bias and misperception in the OR are repetitive problems, as illustrated by the following report:
A surgical arthroscopy of the left ankle was scheduled. The patient was taken to the operating room. Incorrect right leg had tourniquet applied and injected with 5 mL of 1% lidocaine and 5 mL of 0.25% Marcaine™ when circulator realized incorrect site/ side injected. Correct left ankle was then injected and surgery completed.
The alert also identifies that the reports revealed several good catch or near miss events. An example of a reported good catch reflects staff empowerment to “stop the line” when a concern for patient safety and the potential for a wrong-site event is recognized. The following report is an example of staff assertiveness to ensure that best practices are maintained for surgical site marking: Surgeon marked top of patient’s left knee instead of patient’s left foot. The patient was using chlorhexidine wipes preoperatively, and the surgeon did not want to wait to mark the correct site. Site marking was removed by nursing staff, and the surgeon was informed to re-mark the correct site.||12/19/2016 11:26:11 PM||local anesthetic,
chlorhexidine chirurgies de la colonne vertébrale, temps d’arrêt, consentement, procédure spinale au mauvais niveau vertébral ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Incidents|
|Update on Wrong-Site Surgery: More Data Provides More Insight||18669||3872||3/1/2018 7:00:00 AM||Surgery||United States of America||Pennsylvania Patient Safety Authority (USA)||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. ||7/9/2020 3:35:09 PM||gestion de la douleur, blocages nerveux, périopératoire, mauvais côté, trabéculoplastie au laser, urétroscopie, endoprothèse urétrale, amygdalectomie, chirurgie de la main ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Update on Wrong-Site Surgery: Reports from Ambulatory Surgical Facilities||18378||3677||12/1/2016 7:00:00 AM||Surgery||United States of America||Pennsylvania Patient Safety Authority (USA)|| This alert provides an update on the patient safety incidents of wrong-site surgeries in ambulatory surgical facilities. 717 wrong-site operating room (OR) surgery events, including wrong-site anesthesia events which occurred July 2004 through September 2016 were analyzed by the Pennsylvania Patient Safety Authority; an increase in these incidents was identified. The most significant rising trend occurred in the time period of July 2009 to June 2016 showing an increase in incidents from 29% to 34.2%. The most commonly reported events and procedures included the following:
— Wrong side (60.5%): blocks (by anesthesiologists and surgeons), pain management procedures, and eye procedures
— Wrong site (31.8%): excisions and biopsies, pain injections, hand procedures (e.g., incision placement)
— Wrong procedures (7.8%): tonsillectomy (e.g., instead of or in addition to adenoidectomy when only adenoidectomy was intended) and hand procedures (e.g., carpal tunnel surgery instead of trigger finger release).
The three most common types of wrong-site procedures reported since July 2004 have remained consistent and account for about 50% of all wrong-site surgery events:
1. Perioperative anesthesia blocks administered by anesthesiologists and surgeons (25.9%, n = 186 of 717)
2. Spinal procedures (e.g., wrong level; 13.0%, n = 93)
3. Pain-management procedures (11.4%, n = 82).||2/11/2019 10:55:16 PM||mauvais côté, mauvaise procédure, bloc d'anesthésie, traitement de la douleur, excisions, biopsies, procédures rachidiennes, mauvais patient ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Wrong site surgery/Interventional procedure Case 1: Local Anaesthetic (Lignocaine) was Injected to the Wrong Eye||17714||133||10/1/2012 6:00:00 AM||Surgery||Hong Kong||Hong Kong Hospital Authority||This alert describes a patient safety incident where the wrong site was operated on. A patient was admitted for elective repair of retinal detachment of the LEFT eye under retrobulbar anaesthesia. The operation site was marked above the patient’s LEFT eyebrow. Sign in and “time out” were performed by the surgeon and the nurse. The surgeon prepared the anaesthetic drug (2% lignocaine) and injected to the retrobulbar space of patient’s RIGHT eye instead of LEFT eye. The surgeon was informed that the anaesthetic drug was administered into the incorrect eye. The surgeon subsequently injected the anesthetic drug and performed operation on the patient’s LEFT eye. The patient’s RIGHT eye was assessed and no harm was detected.
A contributing factor was that a long time lapse between “time out” and injection of local anaesthetic.
Recommendations to prevent similar patient safety incidents are provided.||7/22/2015 5:50:25 PM||la rétine, anesthésie rétrobulbaire, temps d'arrêt chirurgical, chirurgie au mauvais site ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist|