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Wrong-Site Surgeries Are Preventable
Richard J. Croteau, MD
Arch Surg. 2007;142(11):1111-1112.
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Wrong-site, wrong-procedure, or wrong-patient adverse events are completely preventable and should never happen. Yet these devastating errors continue to plague health care.
In fact, the Joint Commission's Sentinel Event Database receives approximately 9 voluntary reports per month of wrong-site adverse events. This rate has increased since the implementation of the Universal Protocol for Preventing Wrong-Site, Wrong-Procedure and Wrong-Person Surgery in July 2004. The Joint Commission reviewed 83 cases of wrong-site surgery in 2005. The top 3 root causes were communication, 70%; procedural compliance, 64%; and leadership, 46%. Previously, the top 3 root causes from 1995 to 2004 were communication, 78%; orientation and training, 45%; and procedural compliance, 30%.
The hospitals and ambulatory surgery centers that reported wrong-site adverse events to the Joint Commission in 2005 frequently identified surgeon override of the Universal Protocol's strategies as a contributing factor. If wrong-site adverse events are to be eliminated, . . . [Full Text of this Article]
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RELATED LETTER
Wrong-Site Surgeries Are Preventable—Reply
Samuel C. Seiden and Paul Barach
Arch Surg. 2007;142(11):1112.
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RELATED ARTICLE
Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events: Are They Preventable?
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Arch Surg. 2006;141(9):931-939.
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