Wrong-Site Surgeries: How to End the Tragedy? Essay

1142 Words5 Pages
Thousands of incidents of wrong patient and wrong side/site surgeries occur every year in the United States. In general, patient identification errors (PIE) pose the most dramatic consequences that may even lead to patient death. While some PIE lead to taking the wrong medication, others lead to reporting the wrong laboratory or radiological reports to the wrong patient. Interestingly, these drastic scenarios can simply be prevented by following the patient identification protocols which usually rely on using two identifiers or more according to the policy in use. This paper uses the root cause analysis to identify possible actual causes that contribute to the recurrence of PIEs with special highlight to the emergency and surgery rooms. It…show more content…
Lastly, in the surgery theatre, misidentification may happen due to the same factors formerly mention plus failure to mark site/side of surgery, failure to properly perform time-out, and multiple surgical teams (Chan et al., 2010). To analyze the risk for these errors, few factors will be analyzed including human factors (staffing, scheduling, supervision, and qualification), equipment and technology (scanners, computers, and software), Communication (between staff and patients, between staff, between staff and physician, between physician and patient, and between units), environmental factors (physical, safety, security, and preparedness), and procedures and policies (planning, staff education, patient education, protocols, patient identification, and patient observation) (Chan et al., 2010). Human factors With the new healthcare landscape, quality improvement has become a priority; and as required by current legislation, quality initiatives need to be implemented, monitored, and reported (Ransom, Joshi, & Nash, 2008). According to Dattilo and Constantino (2006), human factors play an important role in most errors despite the existence of other root causes. For example, short staffing, shift overlapping, staff level of training and qualifications, close supervision, and overall team and staff culture are all factors that may be the trigger points
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