Pennsylvania Patient Safety Authority Shares Data on Wrong Site Surgery

As reported in Becker's Hospital Review

 Pennsylvania's Patient Safety Authority data showed the share of medical errors attributed to wrong-site blocks  increased from 20 percent of the total in 2004 to 44 percent of the total in 2009. Some anesthesia experts attribute the increase in anesthesia-related wrong site surgery problems to the increased use of nerve blocks. As anesthesiologists use nerve blocks in place of general anesthesia with increasing frequency, they must make sure the correct block site is marked prior to administering the block.

A pilot study conducted by the Joint Commission's Center for Transforming Healthcare at Mount Sinai Medical Center in New York City discovered that Universal Protocol safety checks were not always followed prior to surgery. The hospital created a new process called an "active time-out," in which the surgeon, anesthesiologist and scrub person are each responsible for a series of questions and statements in response to the circulating nurse.


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