The most egregious patient safety incidents

Human error causes patient safety incidents in a myriad of ways. Whilst most of these are near misses and mistakes of only minor consequence, others are serious and particularly distressing for everyone involved. These adverse events are extremely severe in their impact, and because they are also eminently preventable, they have been designated never events. These are patient safety incidents that are apparently inexplicable in their genesis, have life-changing or life-terminating impacts on their victims, and are devastating for the doctors and other healthcare personnel involved.

Perhaps the most catastrophic type of never event is surgery on the wrong patient or on the wrong site. Samuel Seiden and Paul Barach referred to these mishaps as ‘devastating‘ and ‘unacceptable‘, noting that they understandably often result in litigation. In their analysis of several databases of these types of adverse events published in a paper titled Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?, Seiden and Baruch reported that a frightening 1,300 – 2,700 ‘wrong’ type surgeries occur annually in the United States, and that these were most frequent in orthopaedics and dental surgery. Douglas Paull and colleagues, in a paper titled Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration, identified specific operations that have a high risk of wrong site surgery, and these included wrong spinal level operations, wrong site skin lesion excisions, wrong implant cataract procedures, and wrong patient prostatectomies.

Right and left arrows. on Flickr.

To explain the reasons why wrong site and wrong patient surgeries ever happen, Seiden and Barach argued that there is a human cognitive predisposition to confuse the left and right sides, and this gives rise to an ‘inability to maintain right and left sidedness consistently’. Seiden and Barach however also point out that beyond the human tendency to left-right confusion, other external factors drive the risks of wrong site and wrong patient surgery. They referred to these as root error pathologies.

Two arrows with left and right text. Marco Verch Professional Photographer on Flickr.

Perhaps the most important error root pathologies causing wrong site or wrong patient surgery are team communication break-downs and failure of preventative safety systems. These environmental factors which Seiden and Barach identified are:

    • A high workload environment
    • The participation of multiple team members
    • Diffusion of authority
    • Lack of accountability
    • Change of personnel
    • Inexperience
    • Incompetence
    • Fatigue
    • Similar or same procedures back to back in same room

The second root error pathology leading to wrong site or wrong person surgery discussed by Seiden and Barach is what they referred to as ‘ambiguous and imprecise‘ patients and operation site identification. These patient-related factors include:

    • The patient confusing the side, site, or procedure
    • Not cross-checking for inconsistencies in the patient’s consent form or chart
    • Not consulting the patient before anaesthesia
    • Marking the wrong site
    • Not observing the correctly marked site
    • Draping and preparing the wrong side
    • Confusing patients with common names or the same name in the hospital
    • Changing the patient’s position or room before the procedure
Left and right feet tattoos. Amanda Killoran on Flickr.

To reduce the risk of wrong site or wrong patient surgery, Philip Stahel and colleagues, in their paper titled Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences, referred to the Universal Protocol produced by The Joint Commission. The protocol, titled Wrong-Site and Wrong-Patient Procedures in the Universal Protocol EraAnalysis of a Prospective Database of Physician Self-reported Occurrences, stresses the importance of the following measures:

    • Pre-procedure verification
    • Surgical site marking
    • Time-out immediately before the surgical procedure
Left Or Right? Jeremy Brooks on Flickr.

Another important step in preventing surgical errors, including wrong site and wrong patient procedures, is the implementation of the World Health Organisation safe surgery checklist. Atul Gawande, who developed the checklist along with his research team, reviewed its value in his book titled The Checklist Manifesto: How to Get Things Right. There, he noted the importance of the following checklist items in preventing surgical mistakes

    • Observing the huddle
    • Observing pause points
In the next post, we will take a look at the first principles of responding to patient safety incidents.

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