Patient Safety Advisory Report
By Scott E. Diamond
The Pennsylvania Patient Safety Authority recently issued a Patient Safety Advisory Report, which discussed “wrong site” surgeries.
All Pennsylvania licensed hospitals, ambulatory surgical facilities and birthing centers are subject to reporting requirements under Act 13. The Authority developed the Pennsylvania Patient Safety Report System. The Pennsylvania Patient Safety Report System requires all Pennsylvania licensed hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities to submit full reports of “serious event incidents”.
Under Act 13 all Pennsylvania licensed hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities must submit reports of those events to the Authority. In turn the Authority analyzes the collected data to identify trends and recommend changes in healthcare practices and procedures that may be instituted to reduce the number and severity of future serious events and incidents.
More than 400 Pennsylvania facilities are subject to the requirements of this act. The Authority tabulates the reports and analyzes the data to identify trends and suggests improvements to enhance patient safety.
Such a report was recently issued in June of 2007. The agency statistically analyzed wrong site surgeries which had been considered an exceedingly rare adverse event but one that has devastating consequences to both the patient and the healthcare team when it occurs. The agency reported that more than 400 wrong site reports have been submitted, or an average of one wrong site surgery for each year in a 300-bed hospital.
The following chart represents a statistical compilation of wrong site surgery cases in Pennsylvania.
Wrong site surgery involves all surgical procedures performed on the wrong patient, on the wrong body part, wrong side of the body, or wrong level of a correctly identified anatomic site. Wrong patient surgery may include patients, who were never scheduled for a procedure, procedures performed that were not scheduled, and procedures scheduled correctly in which a different one was performed.
More than two-thirds of the wrong site reports submitted to the Pennsylvania Reporting Service felt actual or potential wrong site errors create the most common sites involved in wrong site surgery were procedures relating to lower extremities.
From 1995 through 2003, the Safety Advisory reports that 76% of the wrong site surgery events that occurred were at the wrong site, 13% were on the wrong person, and 11% were the wrong procedure.
The Pennsylvania Patient Safety Authority recently issued a Patient Safety Advisory Report, which discussed “wrong site” surgeries.
All Pennsylvania licensed hospitals, ambulatory surgical facilities and birthing centers are subject to reporting requirements under Act 13. The Authority developed the Pennsylvania Patient Safety Report System. The Pennsylvania Patient Safety Report System requires all Pennsylvania licensed hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities to submit full reports of “serious event incidents”.
Under Act 13 all Pennsylvania licensed hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities must submit reports of those events to the Authority. In turn the Authority analyzes the collected data to identify trends and recommend changes in healthcare practices and procedures that may be instituted to reduce the number and severity of future serious events and incidents.
More than 400 Pennsylvania facilities are subject to the requirements of this act. The Authority tabulates the reports and analyzes the data to identify trends and suggests improvements to enhance patient safety.
Such a report was recently issued in June of 2007. The agency statistically analyzed wrong site surgeries which had been considered an exceedingly rare adverse event but one that has devastating consequences to both the patient and the healthcare team when it occurs. The agency reported that more than 400 wrong site reports have been submitted, or an average of one wrong site surgery for each year in a 300-bed hospital.
The following chart represents a statistical compilation of wrong site surgery cases in Pennsylvania.
Wrong site surgery involves all surgical procedures performed on the wrong patient, on the wrong body part, wrong side of the body, or wrong level of a correctly identified anatomic site. Wrong patient surgery may include patients, who were never scheduled for a procedure, procedures performed that were not scheduled, and procedures scheduled correctly in which a different one was performed.
More than two-thirds of the wrong site reports submitted to the Pennsylvania Reporting Service felt actual or potential wrong site errors create the most common sites involved in wrong site surgery were procedures relating to lower extremities.
From 1995 through 2003, the Safety Advisory reports that 76% of the wrong site surgery events that occurred were at the wrong site, 13% were on the wrong person, and 11% were the wrong procedure.
