Wrong Site Surgery

Gawande in this article applies the surgeon precision to explain to us the reasons behind the uncertainty and the mess of medical care. In addition to this, Gawande provides us with some of the interventions which need to be applied and which will bring relief. This chapter therefore should be read by all students and health professionals. This is because Gawande believes that we can reduce the mistakes within the field of medicine and

According to the Joint Commission Center for Transforming Healthcare, “wrong site survey occurs as often as 40 times per week, in the U.S. Wrong-site surgeries include performing on the wrong side or site of the body, on the wrong patient and performing the wrong surgery” (Wrong-Site Surgery Cited as Top OR Safety Challenge Among U.S. Hospitals, Survey Finds, 2013). Even though, wrong site surgery occurrences are rare, the occurrences however, do occur. Wrong Site Surgery (WSS), is an important topic to address due to the fact that it is considered a preventable medical error, with correct measures, and standardized protocols implemented.

Some of the most common medical mistakes are referred to as surgical never events. This is because it is believed that these errors are preventable, and thus, should not ever happen. According to the Agency for Healthcare Research and Quality, some of the most common surgical never events include the following:

There are number of issues facing healthcare in the United States that are not exclusive to one area and often occur during routine tasks. Although many of these issues are addressed on a daily basis, the need to fix them is still important. Medical errors are a continuous problem seen nationwide in hospitals and surgical centers. More exclusively wrong site peripheral nerve blocks have been seen in hospitals and ambulatory surgical centers across the United States (Hudson, & Sullivan, 2012). The first section of the paper takes a look at a number of reasons why peripheral nerve block errors occur and the risk factors associated with them.

Following the review of a medical error about a 62-year-old woman with skin cancer who experienced wrong-site surgery I will summarize the legal and liability aspects of this case, as well as explore the legal and ethical implications of disclosing errors. In addition, I will discuss the pros and cons of having the provider disclose and empathize for the error to the patient. Finally, I will identify ways the nurse leaders can learn from this situation, help prevent similar kinds of medical errors from happening, and assist the providers and organization to effectively disclose information to patients after such an error occurs.

Mistakes in surgery such as wrong-site, wrong-patient, or wrong procedure occur all to often. These events are termed “sentinel events.” A sentinel event can be described as an accident or mistake that occurs in a hospital or other healthcare setting. These events can cause serious injury or death to a patient. Over the past few decades, major organizations such as the Joint Commission and the World Health Organization have put forth policies to try and decrease the incidence of these mistakes. In 2004 the Joint Commission developed the Universal Protocol. Under this protocol the patient must be identified, the surgical site must also be identified and needs to be marked, and lastly it states that there needs to be a time-out before any procedure occurs. This time out allows the surgical team an opportunity communicate and verify the procedure, the patient, and the correct surgical site. Shortly after this protocol was released, the World Health Organization released a similar protocol, but on a larger scale. This was the “Safe Surgery Saves Lives” campaign. This checklist was spread world wide and included three parts to ensure patient safety in all portions of the surgery; the sign-in phase, the time-out, and the sign-out phase.

You've heard those hospital horror stories where the surgeon removes the wrong body part oroperates on the wrong patient or accidentally leaves medical equipment in the person they were operating on.

Even if no one found out about this mistake, eventually it could happen again if you don’t take the necessary steps to correct your mistake, and this time it could be deadly for your patient.

In spite all the literature, documentation, and the lack of decrease in wrong site surgery, there are still providers who continue to rush and have the philosophy that time is money. Safety events and adverse events cost a lot of money (Laureate Education, 2010). Although adherence to universal protocol is required by Joint Commission since July 1, 2004, wrong site, wrong procedure, and wrong patient errors still occur. The incidence of wrong site surgery can be improved but needs to have the full participation of everyone involved in the process. Some of the reasons believed to add to the risk of wrong site surgery include poor planning, lack of

Wrong site surgeries are rare, however, they can be devastating to the patient and members of the surgical team (Carney, 2006). They are usually caused by not having a formal policy in place (Saufl, 2004). Multiple policies, including one by the WHO, are currently being utilized to prevent theses errors, however, they are still occurring, just at a reduced number. The goal of quality improvement is to prevent the issues from happening all together and increase the safety for the patient (Williams & Torrens, 2008).

Though confusions are more likely to happen in emergency operations, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) reported that 58% of surgical confusion occurred in ambulatory patients and 29% involved inpatients. Wrong site confusions occurred in 76% of cases, wrong patient in

Wrong person, wrong procedure, and wrong site surgery instances are a growing problem throughout the country. While most would agree that determining a true number is difficult due to underreporting and difficulties in defining exactly what constitutes a wrong site surgery, it is a mounting patient safety concern. There is no way to identify all of the potential patient safety concerns, because the possibilities are dependent on what was performed.

Whether the surgeon is a resident or an experienced attending, in the process of performing any surgery, mistakes are inevitable. However, in the case of the attending, the quantity and nature of the error should be less frequent than that of the resident. Among the interns, the three most common errors are technical, judgmental, and normative; and among attendings the quasi-normative error is most common. Thus, a technical error is defined as any error that is reported and treated immediately. When this does not happen, the interns level of training is questioned. In the case of judgmental error, an incorrect

Consequently, since there was no notification of an error that the operator could see, she continued with the process treatment on her patients. The occurrence of this error is categorized as a commission because the act was performed incorrectly. Since the operator typed the key command too quickly that it caused her to mess up the operating command, she tried to recover her mistakes by using the “editing” function at a very fast pace that was not fit for the program. Some contributing events that led up to the error are the presence of cameras within the treatment room, but it was not checked to see if it was up and running during the treatment. Another is the inoperative voice

Terrible mistakes can happen during surgery. Each year in the U.S. alone, surgical mistakes result in tens of thousands of innocent surgical patients suffering serious injury, paralysis, or even death. These mistakes are committed by surgeons, surgical and hospital staff, and other health care providers. Many causes of surgical errors are sometime inattentive or distracted surgeons