The group found that the implementation of eight processes reduced the number of wrong-site sentinel events by 72% from the 12-month period starting in October 2007 to the 12-month period from April 2009. Those processes included:
The processes included significant detail, including site marking in various stages, such as prior to sedation and done with a discussion with the patient and verified with radiographic information.
The group also conducted unannounced observational assessments of non-emergent surgical cases to help surgeons and their teams identify practices where errors might occur.
"The PPC's regional initiative was successful in accelerating the rate of improvement in preventing wrong site surgery for the participating hospitals," the authors wrote in Patient Safety & Quality Healthcare.
During the same period that this study took place, wrong site-surgery prevention also became a national priority, and the study found that wrong-site surgery events in non-participating Pennsylvania hospitals also declined during the period by 32%.
It surprised me that wrong-site surgery and these near misses are a major component of sentinel events across the country, because I had considered these extremely rare events. And they are, but not as rare as I thought. I am sobered by the discovery and again chagrined that I would even consider joking about such an event.
Moreover, so much the better that concerted efforts now take place to make these avoidable tragedies disappear.
I phoned Averill yesterday to tell him about this column. He remembered my feeble joke—even though it was more than a decade ago. These days at his hospital, he says, there are so many checks at so many points, prior to surgery that the matter of wrong site surgeries remains a very big deal.