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Preventing Wrong Site Surgery – A Quarterly Update From The Pennsylvania Patient Safety Authority (PSA)

Posted Oct 04 2010 12:00am

Of particular interest is that the number of reports for wrong site surgery in Pennsylvania appear to be declining.  However, wrong site placement of local anesthetic blocks is becoming an increasing percentage of the reports.  For example wrong site blocks constituted 20% of the wrong site events in the first six months of data reporting to the PSA, but they accounted for 44% of wrong site events in the most recent six months of reporting.  These are two of the four examples provided by the PSA: 1) a patient was scheduled for a surgical procedure on the left hand under axillary block. The anesthesiologist blocked the right arm. The correct arm, left, was marked appropriately. The error was discovered by the anesthesiologist after initiating the block.  2) A patient was admitted for surgery [on the right knee]. The patient was seen by the anesthesiologist who asked the patient which knee was to be operated on. The patient stated “left.” The anesthesiologist performed the nerve block on the left side. The patient was taken to the OR for the right-knee surgery where it was determined the nerve block was done on the wrong side.  Doing a formal time-out before an anesthetic block could potentially eliminate about 27% (92 of 337) of the wrong site errors reported in the surgical suite. However, based on the data from the Preventing Wrong-Site Surgery Project, a time-out before an anesthetic block does not eliminate the need to do a time-out just before the start of the surgical procedure, with the site marking visible in the prepped and draped surgical field.

In the opinion of the PSA, the 2010 revision of the Joint Commission’s Universal Protocol does not help the confusion about when to do the time-out.  The 2009 version states that the time-out should be done before the start of anesthesia; the 2010 version reverts to stating that the time-out should be done before the incision.  Based on multiple studies from the Preventing Wrong-Site Surgery Project, the Authority strongly advises that a formal time-out be done with the anesthesia provider just before any anesthetic block is placed and that another time-out be done with the surgeon just before the incision, unless the surgeon performs the anesthetic block and incision in continuity after the surgical field has been prepped and draped. 

Ref: Pennsylvania Patient Safety Advisory 2008;6:141-143

David S. Smith M.D., Ph.D.

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