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A1264
October 25, 2005 2:00:00 PM - 4:00:00 PM Hall C4 |
| Wrong-Sided Anesthetic and Surgical Procedures: Why Do They Continue To Happen? |
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Paul R. Barach, M.D., M.P.H., Samuel Seiden, B.A., Marshall F. Gilula, M.D. Anesthesiology, Center for Patient Safety, University of Miami/Jackson Memorial Hosp., Miami, Florida, United States |
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Introduction: Wrong-sided procedures are one of the worst imaginable events for a patient and surgical team. Bilateral organ symmetry creates the potential for wrong-sided anesthesia and surgery, especially for percutaneous procedures such as nerve blocks. The prevalence of wrong-sided surgeries is documented, but data for wrong-sided anesthesia are lacking. Meinberg identified 242 cases of wrong side/finger surgery among orthopedic hand surgeons, estimating a lifetime risk of performing a wrong side surgery at one in five surgeons [1]. However, these estimates rely on self-reporting, and evidence suggests they underestimate the incidence of wrong-sided events by a factor of 20. No published studies have discussed the prevalence of wrong side anesthetic procedures. Preventing adverse events requires understanding how and where the systems and cognitive failures occur. Methods: We report multiples sources to demonstrate that these eventss are more common than currently recognized. From 1995-2003 JCAHO identified 278 wrong-site procedures, whereas the National Practitioner Databank recorded 5,940 events (2,217 wrong side surgeries, 3,723 wrong treatment/wrong procedure errors) occurring steadily over 13 years. We report on 17 cases reported through a novel web-based system for collecting cases www.wrong-side.org. Results: Wrong-sided procedures in 17 cases are presented as follow up to our first report [2]. The limitations of this small case series obtained by convenience sample are many, but analysis of the data from 7 cases suggests that risk factors for performing a wrong-sided procedure include: female gender (n=5); older age (n=6); ambulatory surgery setting (n=5); left-sided procedure (n=6); regional anesthesia (n=6); and surgery during high clinic workload (n=6). The involvement of multiple team members (n=7) did not prevent laterality errors, nor did "paper-checks" such as checklists (n=3), laterality specified on consent form (n=6), or laterality policies (n=5). Discussion: The preponderance of older female patients, left-sided regional anesthesia, and outpatient, high-workload environments warrant further study. Why existing laterality checks such as checklists and site signing are not effective is unclear. Our preliminary analysis suggests that wrong sided anesthesia events are more common than reported and that present solutions to prevent these events are sub optimal. Educational and preventive strategies that focus on cognitive and systems solutions have the potential to stop wrong sided adverse events. The essence of the JCAHO intervention, a time-out, occurs after anesthesia has been administered, and thus does not prevent anesthesia related errors.Systems practices to successfully reduce wrong-sided procedures will likely combine a standard method of reliable site marking supported by a collaborative team and human factors/systems effort. References: 1. J Bone Joint Surg Am, 2003. 85-A 193-7. 2. Anest Analg 2003;96:S101. Anesthesiology 2005; 103: A1264 |