Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Database of Physician Self-reported Occurrences | Surgery | JAMA Surgery | JAMA Network
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Original Article
October 2010October 18, 2010

Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Database of Physician Self-reported Occurrences

Author Affiliations

Author Affiliations: Departments of Orthopaedic Surgery (Dr Stahel), Neurosurgery (Dr Stahel), and Internal Medicine (Drs Boyle and Mehler), Denver Health Medical Center and University of Colorado School of Medicine, Denver; Department of Patient Safety and Quality, Denver Health Medical Center (Drs Sabel and Mehler); Department of Biostatistics and Informatics, University of Colorado (Dr Sabel); Colorado Physician Insurance Company, Denver (Drs Victoroff, Varnell, Lembitz, Boyle, and Clarke); and Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, Pennsylvania (Dr Smith).

Arch Surg. 2010;145(10):978-984. doi:10.1001/archsurg.2010.185

Objective  To determine the frequency, root cause, and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol.

Design  Analysis of a prospective physician insurance database performed from January 1, 2002, to June 1, 2008. Deidentified cases were screened using predefined taxonomy filters, and data were analyzed by evaluation criteria defined a priori.

Setting  Colorado.

Patients  Database contained 27 370 physician self-reported adverse occurrences.

Main Outcome Measures  Descriptive statistics were generated to examine the characteristics of the reporting physicians, the number of adverse events reported per year, and the root causes and occurrence-related patient outcomes.

Results  A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a “time-out” (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.

Conclusions  These data reveal a persisting high frequency of surgical “never events.” Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.