Here I was, enjoying a very tasty Key Lime Cheese Torta (with cranberries) from Oregon’s Rising Sun Farms (www.risingsunfarms.com) when up through my stack of papers comes this show-stopper:
Insight into Preventing Wrong-Site Surgery
©2007 Pennsylvania Patient Safety Authority Page 1
Produced by ECRI Institute & ISMP under contract to the Patient Safety Authority
W rong-site surgery can be national news, as it
was in November 2007 when Rhode Island
Hospital was fined $50,000 for doing their third
wrong-side craniotomy of the year.1 Although the
frequency of wrong-site surgery has decreased in
Pennsylvania, PA-PSRS continues to receive reports,
despite disseminating information from our
retrospective analysis of wrong-site events and near
misses (see Figure 1).2,3 To gain further insight into
the elusive and apparently intractable causes of
wrong-site surgery, we have undertaken a number
of initiatives. We have done site visits at volunteer
facilities. We have begun collecting specific detailed
information about wrong-site surgery near misses
and actual events. We will be setting up a Web resource
that will provide the latest information for facilities
interested in decreasing their risks for experiencing
wrong-site surgery.
Here, we will summarize our insights and conclusions
from our site visits and give some preliminary
findings from our in-depth queries of wrong-site surgery
events and near misses. We intend to contribute
a detailed analysis of our observations in the
future. These insights and conclusions form the basis
of a self-assessment checklist that facilities can
use to evaluate and monitor their programs for preventing
wrong-site surgery (this checklist is available
online; for information, see the Web resource sidebar
on page 6).
Read the full report here: www.psa.state.pa.us
Over a 30-month period there were 174 incidents wherein patients had surgery on the wrong body part. And there were 253 “near misses”!! Oh my god, I am having a Jerry Seinfeld moment. Who the heck is doing these surgeries?? Kosmos Kramer???
