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Root cause analysis should be conducted after a wrong site surgery to reduce future errors

On average, five to eight cases of wrong site surgery (wrong side or site of the body, wrong procedure, or wrong-patient surgeries) are reported each month to the Joint Commission on Accreditation of Healthcare Organizations. A typical case of a man who had surgery on the wrong knee (left knee instead of right knee) is outlined in a recent article by Pascale Carayon, Ph.D., of the University of Wisconsin-Madison, and colleagues. Their work was supported by the Agency for Healthcare Research and Quality (HS11561).

A root cause analysis based on human factors engineering (HFE) analysis revealed several work system elements that contributed to the wrong site surgery. In this case, after the initial visit with the patient, the surgeon handed the patient's record to the nurse, asking her to schedule surgery for the right knee. The nurse, bogged down in a heavy workload that day, did not find time to schedule the surgery until the end of the shift, when she had forgotten which knee was to have surgery. Consequently, she scheduled it for the left knee after seeing some notes about problems with that knee. On the day of the surgery, the nurse read the consent form to the hard-of-hearing patient in the noisy preop area, the patient assumed that the nurse said the surgery was to be on the right knee, and he signed the consent. The surgeon arrived, corrected the consent form to indicate the right knee but was called back to prior surgery before he could change the surgery schedule. At this point a resident surgeon was called in to begin the knee surgery and, when the original surgeon returned to the operating room, he discovered that surgery was underway on the wrong knee.

The nurse's high workload, the noisy preoperative environment, and unavailable technology for the surgeon to immediately record the surgery procedure at the time of the decision and to change the surgery schedule at the same time he revised the consent form all contributed to the wrong site surgery. Correcting these problems may reduce future mistakes.

Details are in "Righting wrong site surgery," by Dr. Carayon, Kara Schultz, and Ann Schoofs Hundt, Ph.D., in the July 2004 Joint Commission Journal on Quality and Safety 30(7), pp. 405-410.

Editor's Note: Another paper on a related topic provides a practical framework for improving patient safety in the complex environment of the intensive care unit. For more details, see Pronovost, P.J., Wu, A.W., and Sexton, J.B. (2004, June). "Acute decompensation after removing a central line: Practical approaches to increasing safety in the intensive care unit." (AHRQ grant HS11902). Annals of Internal Medicine 140, pp. 1025-1033.

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