Wrong Person, Wrong Procedure, And Wrong Site Surgery

In accordance with the World Health Organisation (WHO 2008) checklist and Local trust policies, a team briefing was held before the day’s list started. The checklist is part of a second Global Patient Safety Challenge initiative entitled ‘Safe Surgery Saves Lives’, aimed at reducing the number of surgical deaths worldwide and was launched in June 2008. This not

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct

The surgical team’s performance depends on open dialogue and an understanding of each member’s role. (Gillespie, Gwinner, Chaboyer & Fairweather, 2013). In this study, participants were asked a series of questions and their answers were then analyized. It was determined that the ability for team members to build shared understandings through open verbal communication is crucial to enhance performance within the surgical suite. In my experience, open communication is the key to being successful as a circulator in the operating room. Patient outcomes become better when open communication is used between all parties from the schedulers to the staff in the rooms. Without proper clarification through verbal, written and nonverbal communications, the incorrect procedure could be performed on the incorrect

In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

As noted by Haugen, Murugesh, Haaverstad, Eide, and Softeland (2013) wrong site surgery continues to be a problem that can be prevented through the use of a checklist. In 2008, WHO published guidelines to ensure the safety of surgical patients. The guidelines included

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

Wrong-site surgery is a serious and preventable occurrence, however, it continues to be a problem in

Due Date: Document will be due at the committee’s second meeting from now. If the committee

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

Wrong site surgeries are very rare, but sometimes wrong site surgeries happen. The wrong site surgeries have damaging results for the patient and pose a huge safety problems within the organization. Usually communication breakdown is considered the main cause of wrong site surgeries in the surgical team. The Joint Commission 's universal protocol of "time out" is a very important and a helpful tool in preventing the wrong site surgeries, wrong person surgery, and wrong procedure.

Wrong site surgery remains the most frequently reported sentinel event, with 908 wrong site surgeries reported since 1995 (AORN, 2010). During the late 1990’s and early 2000’s there was a tremendous public concern and lack of trust for the medical profession, especially within surgical services. We as healthcare professionals needed to step up to the plate, slow down, and take responsibility to improve the quality of care we provide for our patients. Although there still is some resistance from surgeons and other healthcare professionals, overall there has been a general acceptance to universal protocol.

Even if the doctor was not aware of this risk and did not strive to educate himself about the possible complications given the patient's fragile conditions, he should still have not assured her that there was "nothing to worry about," given that all surgical procedures entail some risk, including the risk of infection. And while no physician can keep current with every development in the field of medicine, there is some basic, minimum demand for professional education. To prevent future liability risks, physicians should be instructed on how to use language in expressing risk to the patient and be careful to avoid colloquialisms that could mislead them such as "there is nothing to worry about" and "you'll be fine." Physicians must also more carefully

There are many elements needed to provide a safe surgical experience. It takes a team consisting of the surgeon, anesthetist, circulator, scrub nurse, and assistant/retractor to perform many surgical procedures. Team communication is of utmost importance. When a breakdown occurs, patient safety can be at risk. If any team member has or notices a safety concern, it is imperative that the issue is communicated and everyone stop to address the problem. Patient safety concerns can be related to things such as surgical fires, incorrect positioning, retained surgical items, wrong site surgery or surgical site infections.