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Wrong Site Surgeries Still a Threat

Cheryl Clark, for HealthLeaders Media, October 14, 2010

According to the commission's August report, there were 921 wrong-site surgeries reported between Jan. 1, 1995 and June 30, 2010, of which 31 occurred in the first six months of this year. That's more than other leading sentinel events, including hospital suicides, operative or post-operative complications, delays in treatment and medication errors. Wrong site surgery, as a category, makes up nearly 18% of all reported sentinel events.

Just last year at Parkview Community Hospital in Riverside, CA, for example, multiple process errors resulted in a surgeon taking out a patient's right kidney instead of the damaged left one.

According to documents filed by the state, the doctor lacked staff privileges to perform kidney surgery at the time. Additionally, the Spanish-speaking patient was not given an opportunity to give full, informed consent for the procedure, the documents said.

The patient had to undergo another surgery to take out the diseased kidney, and as a result, now undergoes dialysis two-to-three times a week for four hours at a time, the documents said.

Another wrong-kidney procedure occurred at Park Nicollet Health Services, MI a year earlier. And in San Diego, surgeons last year removed the wrong side of the skull of a 93-year-old man in for a brain bleed repair, according to state documents. I could go on.

Now hospitals are gearing up in even bigger ways to prevent such costly and life-altering mistakes, and it can be done, according to the report, "Preventing Wrong-Site Surgery" published by Patient Safety & Quality Healthcare, in collaboration with the ECRI Institute.

In Pennsylvania, where hospitals had a significant wrong site surgery problem, a wrong-site surgery prevention project took shape with funding by Independence Blue Cross and the hospital community, Partnership for Patient Care (PPC), led by the non-profit HealthCare Improvement Foundation.

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1 comments on "Wrong Site Surgeries Still a Threat"


Gretchen Hammer (10/15/2010 at 8:48 AM)
The coming opening of our newly renovated operating room was the perfect time for our hospital's Quality Improvement Patient Safety Committee to be updated on OR policies/procedures. We were delighted to learn that we have many checkpoints installed in the surgical unit, including Time-Out, when each member of the OR team announces who s/he is and what the procedure is for the day, as well as what that person's role is....