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Wrong-Site Surgery

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Patient Safety

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Abstract

The Joint Commission initiated its sentinel event policy in 1995 as a method to identify and track leading causes of medical errors and unexpected deaths within the USA. Wrong-site surgical (WSS) procedures ranked the highest among 4,074 sentinel events reported to the Joint Commission between January 1995 and December 2006.

Factors that have been shown to increase the risk for wrong-site surgery and invasive procedures include comorbid and bilateral disease, morbid obesity or physical deformity, incomplete or inaccurate communication, poor booking processes, unusual time pressures, emergency procedures, and the need for multiple procedures or multiple surgeons.

In 2004, the Joint Commission implemented its “Universal Protocol” procedure in an effort to reduce the incidence of wrong-site and wrong-patient procedures. The protocol mandates that a three-step process be performed before the start of any invasive procedure or surgery. The three steps include a verification process, marking of the operative site, and a final time-out process to reconfirm the right patient, the right procedure, and the right site/side.

Prevention of WSS requires strict adherence to the protocol, good teamwork, and aggressive education of all employees in the risk factors and root causes for these events. But above all, it requires constant vigilance by all practitioners who participate in invasive procedures and a complete commitment to promote patient safety and avoid patient harm.

“What are man’s truths ultimately? Merely his irrefutable errors.”

Frederich Nietzsche

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Authors and Affiliations

  1. Department of Surgery, SUNY-Downstate/Kings County Hospital Center, Trauma Office 451 Clarkson Avenue, Room C-3211, Brooklyn, NY, 11203, USA

    Patricia Ann O’Neill R.N., M.D., F.A.C.S.

  2. Department of Surgery, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA

    Eric N. Klein M.D.

Authors
  1. Patricia Ann O’Neill R.N., M.D., F.A.C.S.
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  2. Eric N. Klein M.D.
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Correspondence to Patricia Ann O’Neill R.N., M.D., F.A.C.S. .

Editor information

Editors and Affiliations

  1. Norwegian American Hospital, Chicago, Illinois, USA

    Abha Agrawal

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O’Neill, P.A., Klein, E.N. (2014). Wrong-Site Surgery. In: Agrawal, A. (eds) Patient Safety. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-7419-7_10

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  • DOI: https://doi.org/10.1007/978-1-4614-7419-7_10

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  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4614-7418-0

  • Online ISBN: 978-1-4614-7419-7

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