HARRISBURG -- Wrong-site surgery data received by the Patient Safety Authority shows that every other day in Pennsylvania healthcare facilities an actual adverse event or near miss of a wrong-site surgery occurs. The Authority released its 2007 June Patient Safety Advisory containing the data in a press conference held in Harrisburg today.

"To be frank, wrong-site surgeries in Pennsylvania should never occur. However, every other day in Pennsylvania we have a report of a wrong-site surgery being caught either before or after the start of an operation," said Dr. Stan Smullens, chief medical officer of the Jefferson Health System and Vice-President of the Patient Safety Authority Board of Directors. "However, we are not alone. Wrong-site surgeries are no more common in Pennsylvania than they are in other states. We also have in common with other states the problem of trying to fix them."

In a 30-month time period (June 2004 - December 2006) the Authority received 427 near misses and serious events of wrong-site surgeries. Of those, 253 were near misses or did not reach the patient.
"Of those events that reached the patient in the operating room, sixty-nine percent were wrong side surgeries, fourteen percent were wrong body part surgeries, nine percent were wrong procedure and eight percent were wrong patient," added Smullens. The most common sites where the wrong-site occurred were extremities, eyes and spine. Orthopedic and ophthalmologic procedures were the most common for wrong-site surgeries.

Smullens added that risk factors for wrong-site surgery include: multiple procedure and/or multiple surgeons; communication breakdowns; time pressures; incomplete preoperative assessments; and organizational cultural factors that are not conducive to promoting teamwork such as an attitude that surgeons decisions should never be questioned. However, he added that in many reports the patient or family member was responsible for correcting information that prevented the wrong-site surgery from occurring. The Authority has provided a consumer tip sheet for patients and families made available on its website at www.psa.state.pa.us under "Tips for Consumers."

"We know that patients and family members have been important components in stopping wrong-site surgeries from happening," said Smullens. "So, we've developed a consumer tip sheet that provides patients and family members with advice to ensure they participate in their healthcare and reduce the likelihood of a wrong-site surgery."

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