Wrong–Site Surgery: Does That Really Happen?

It’s going to be a busy day in the operating room (OR). The orthopedic group has a full caseload, neurosurgery is performing four spinal cases. The new general surgeon has two gall bladder cases and anesthesia is doing a half-dozen pain management injections in the block room. The first case of the day has been delayed, as an auto accident on the freeway has the surgeon stuck in traffic. The preoperative care unit is filled with anxious patients and their significant others. Transport personnel are arriving with patients from the nursing units as staff are busy starting intravenous lines and initiating preop orders. All in a coordinated effort, preparing for surgical procedures. What could possibly go wrong

Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.</jats:p

Online Supplement to "Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities"

This supplementary material has been provided by the authors to give readers additional information about their work.</jats:p