Despite years of emphasis on using the Universal Protocol and site marking, wrong-site errors occur in about one in 100,000 surgeries, according to a recent study in the journal Surgery.
The review for the U.S. Veterans Affairs National Center for Patient Safety was conducted by Susanne Hempel, co-director of the Evidence-based Practice Center at the RAND Corp., a nonprofit global policy think tank with headquarters in Santa Monica, CA, and her colleagues. Their goal was to evaluate the incidence of wrong-site errors 10 years after the introduction of the Universal Protocol.
The most frequent contributing factors for wrong-site surgery involved communication issues, the study found. In some cases, staff provided incorrect information or accurate information was misunderstood by the receiver, and in others, important information was not made available to the OR team. The researchers also found instances of surgical team members not voicing their concerns about the accuracy of a procedure and some in which members did speak up but were ignored.
In 138 studies published from 2004 to 2014, the frequency of wrong-site surgery, leaving an item behind in a person during surgery, and surgical fires varied according to the particular procedure and how data was collected. In one example, a study of ophthalmology claims found 0.5 wrong-site events per 10,000 procedures, but a survey of ophthalmologists who perform procedures to correct strabismus determined there were four wrong-site events per 10,000 procedures.
The study is available online at http://tinyurl.com/qf3dbyc.