geoscience.net logo
+ Resolve Article
+ Follow Us
Follow on FacebookFollow on Facebook
Follow on TwitterFollow on Twitter

+ Translate
+ Subscribe to Site Feed
GeoScience Most Shared ContentMost Shared Content

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable?


, : Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable?. Archives of Surgery 141(9): 931-939

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) are devastating, unacceptable, and often result in litigation, but their frequency and root causes are unknown. Wrong-side/wrong-site, wrong-procedure, and wrong-patient events are likely more common than realized, with little evidence that current prevention practice is adequate. Analysis of several databases demonstrates that WSPEs occur across all specialties, with high numbers noted in orthopedic and dental surgery. Databases analyzed included: (1) the National Practitioner Data Bank (NPDB), (2) the Florida Code 15 mandatory reporting system, (3) the American Society of Anesthesiologists (ASA) Closed Claims Project database, and (4) a novel Web-based system for collecting WSPE cases (http://www.wrong-side.org). The NPDB recorded 5940 WSPEs (2217 wrong-side surgical procedures and 3723 wrong-treatment/wrong-procedure errors) in 13 years. Florida Code 15 occurrences of WSPEs number 494 since 1991, averaging 75 events per year since 2000. The ASA Closed Claims Project has recorded 54 cases of WSPEs. Analysis of WSPE cases, including WSPE cases submitted to http://www.wrong-side.org, suggest several common causes of WSPEs and recurrent systemic failures. Based on these findings, we estimate that there are 1300 to 2700 WSPEs annually in the United States. Despite a significant number of cases, reporting of WSPEs is virtually nonexistent, with reports in the lay press far more common than reports in the medical literature. Our research suggests clear factors that contribute to the occurrence of WSPEs, as well as ways to reduce them. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events, although rare, are more common than health care providers and patients appreciate. Prevention of WSPEs requires new and innovative technologies, reporting of case occurrence, and learning from successful safety initiatives (such as in transfusion medicine and other high-risk nonmedical industries), while reducing the shame associated with these events.

US$19.90

PMID: 16983037

DOI: 10.1001/archsurg.141.9.931


Other references

Pourabedin, M.; Xu, Z.; Baurhoo, B.; Chevaux, E.; Zhao, X., 2014: Effects of mannan oligosaccharide and virginiamycin on the cecal microbial community and intestinal morphology of chickens raised under suboptimal conditions. There is an increasing movement against use of antibiotic growth promoters in animal feed. Prebiotic supplementation is a potential alternative to enhance the host's natural defense through modulation of gut microbiota. In the present study,...

Fan, L.; McIntosh, T.K., 1994: Effect of dynorphin microinjection in the paraventricular nucleus on the hemodynamic response to hemorrhage in the rat. We studied the effect of dynorphin A-(1-13), dynorphin A-(1-17), des-tyr dynorphin A-(2-17) (inactive at opioid receptor) or normal saline (NS) microinjected into the paraventricular nucleus (PVN) (n = 9/treatment) on mean arterial pressure (MAP),...

Souza, E.; Follett, P.A.; Price, D.K.; Stacy, E.A., 2008: Field suppression of the invasive ant Wasmannia auropunctata (Hymenoptera: Formicidae) in a tropical fruit orchard in Hawaii. The little fire ant, Wasmannia auropunctata (Roger) (Hymenoptera: Formicidae), is an invasive ant that forms supercolonies when it successfully invades new areas. W. auropunctata was first reported in Hawaii in 1999, and it has since invaded a var...

Gukovich V.A.; Chudnovskii S.I.; Moroz B.S.; Chaika S.P.; Polyakov A.N., 1985: Truncus cerebri acoustic evoked potentials in acoustic and electrical stimulation of the cochlea in guinea pigs. Vestnik Otorinolaringologii (5): 63-64

Kotsiomiti, E.; Kapari, D., 2000: Resting tongue position and its relation to the state of the dentition: a pilot study. The position of the resting tongue has been reportedly classified as normal or abnormal. The problems introduced by the abnormal tongue position relating to denture retention and stability have been sufficiently underlined. In the present study, t...

Campbell, J.R., 1984: Studies on Plasmodium falciparum. To make results comparable between laboratories it is recommended that all fresh isolates of P. falciparum to be put into continuous culture should have an aliquot frozen from the original blood and from every 10th in vitro passage. In reporting r...

Vihko P.; Kontturi M.; Lukkarinen O.; Martikainen P.; Pelliniemi L.; Heikkila J.; Vihko R., 1987: Immunoscintigraphic evaluation of lymph node involvement in prostatic carcinoma. Five patients who were candidates for radical prostatectomy were investigated. One milligram of diethylene triamine pentaacetic acid derivatives of purified F(ab')2 fragments of monoclonal antibodies against prostatic acid phosphatase, labele...

Mattocks P.W.Jr, 1988: The autumn migration august 1 november 30 1987 northern pacific coast region usa canada. American Birds: 121-126

McGhee, M.F., 1990: No endocervical cells: an update. British Journal of General Practice 40(333): 168-168

Meeinkuirt, W.; Pokethitiyook, P.; Kruatrachue, M.; Tanhan, P.; Chaiyarat, R., 2012: Phytostabilization of a Pb-contaminated mine tailing by various tree species in pot and field trial experiments. The potential of 6 tree species (Leucaena leucocephala, Acacia mangium, Peltophorum pterocarpum, Pterocarpus macrocarpus, Lagerstroemia floribunda, Eucalyptus camaldulensis) for phytoremediation of Pb in sand tailings (total Pb >9850 mg kg(-1))...