Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events

Abstract

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.Design: 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). Results:The NPDB recorded 5940 WSPEs (2217 wrongside surgical procedures and 3723 wrong-treatment/wrongprocedure errors) in 13 years. Florida Code 15 occurrences of WSPEs number 494 since 1991, averaging 75 events per yearsince2000.TheASAClosedClaimsProjecthasrecorded 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.Conclusions: 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.

The Insidious Problem of Fatigue in Medical Imaging Practice

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Haplotype Counting by Next-Generation Sequencing for Ultrasensitive Human DNA Detection

“…Although rare, wrong-patient adverse events occur in hospital settings, especially when patients share the same name or patients have similar appearances. 39 To circumvent these preventable errors, a biological identifier, such as those described herein, could be implemented to unequivocally distinguish patients.…”

Evaluation of the risk of misidentification of women in a public maternity hospital

“…Over the years, identification wristbands with information about the patient have been used as a method to avoid misidentification, but evidence suggests that the inadequate use of this instrument can offer risks to patient safety (5) . Nonconformities in patient identification include ambiguous labeling, simultaneous presence of homonymous or paronymous patients, high bed turnover and flaws in communication or security systems, such as absence or inaccessibility of identification wristbands (6) . In addition, there are facts that add to the problem, such as the high incidence of homonyms and presence of patients whose names have similar spelling or pronounciation.…”