These "wrong-site, wrong-procedure, wrong-patient errors" WSPEs are rightly termed never events —errors that should never occur and indicate serious underlying safety problems. Wrong-site surgery may involve operating on the wrong side, as in the case of a patient who had the right side of her vulva removed when the cancerous lesion was on the left, or the incorrect body site.
This long, but not exhaustive, list contains factors that are present in many theatres. As in so many of these Wrong site surgery in which adverse events occur, the more contributing factors that are present, the more likely it is that WSSwill occur.
How can Wrong site surgery errors be prevented? It was mentioned in the section above, that WSS errors occur because of the lack of a system to verify the correct site or if a system is established then a breakdown within it.
It is therefore obvious that reducing or eliminating these types of errors involves setting up robust systems. This has been recognised by a number of national organisations that have thought that WSS was a preventable occurrence and that robust checking systems were the best method of prevention.
There is a general agreement between these organisations that reducing WSS errors involve two elements: Creation and use of a preoperative verification process Implementation of a system for marking the surgical site. More specifically, there are a number of important components that make up these two goals: Involvement of the patient in the consent and surgical site marking process.
It has even been suggested that the patient makes his or her own mark 11 Participation of all the surgical team in verifying the operative site—the JCAHO suggests an oral verification between team members of the correct site.
This involves a few minutes in which all members of the team make a final verification of the correct patient, procedure, site, and any other components applicable to the surgery for example, the intraocular lens power or examining the fundus of the eye to be removed Rules for marking of the operative site: Other suggestions for making errors less likely include: Health organisations fostering an atmosphere in which errors are openly reported and discussed Avoiding using abbreviations for left and right and for structures—for example, LR or MR.
Make sure all implants are obtained and checked before starting the procedure rather than during it. As human beings are, and always will be, fallible, electronic systems have been devised that can reduce the potential for human error: Bar coding 12 —this has been used in a number of areas within health care when identification needs to be robust.
Examples include blood transfusions, medications, and surgical instruments Surgichip AMTSystems —this is a system that uses radio frequency identification technology.
Patient details including name, operative location, date of surgery, and the operative procedure are fed into the system and adhesive labels are produced containing a computer chip with this information. The ultimate goal is to produce a single national or even international system for identifying and marking operative sites.
The more widely used a system is the more familiar staff and patients become within it even when they move between hospitals or healthcare systems and therefore the more likely it is to be successful.
If the patient is under general anaesthesia, the appropriate steps to return the incorrect operation to as near the preoperative situation should be undertaken. Unless there are medical reasons the correct operation should then be performed.
If under local anaesthesia the patient should be informed of what has happened and have the steps that you will undertake explained as for general anaesthesia unless the patient disagrees with this course of action.
The incident needs to be reported to the appropriate local and national bodies when a root cause analysis should be undertaken to identify any learning issues. Summary WSS is an uncommon but potentially catastrophic event. It can occur in a number of circumstances but is most common in surgery that involves paired organs or multiple sites.
Certain factors have been shown to make it more likely and these have been used to create guidelines and protocols to reduce the occurrence of WSS.About Dr. Payman Simoni. When other doctors decide to undergo cosmetic surgery and are looking for the best facial plastic surgeon Beverly Hills has to offer, Dr.
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