Wrong site surgery case
[PDF File]PDF Wrong Site Surgery - New York State Department of Health
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]Wrong site surgery is rare—(1:100,000)]Most wrong site surgery cases (64%) result in no permanent injury.]There are many types of adverse events that are more frequent and more harmful.]So why do we spend so much time and energy on it?
[PDF File]PDF Patient Safety Workshop Case Example - New Jersey
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PATIENT SAFETY WORKHSOP WRONG SITE SURGERY EXAMPLE From Event Report: 42-year-old male admitted for right arthroscopy on 12/23/04. Surgery performed on left knee. Patient informed. After Investigation as part of RCA Process: • Mr. C., a 42-year-old former dancer and now choreographer, was admitted at 7 AM, for
[PDF File]PDF A protocol for the reduction of surgical errors
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For wrong site/wrong side surgery the JCAHO has so far reported 150 cases, with root cause analysis available for 126: 75% were on the wrong body part or site, 13% were for wrong patient surgery, and 11% for the wrong surgical procedure. Over 80% of these incidents were self-reported, with the remainder arising mainly from patient complaints.
[PDF File]PDF Review of correct site protocol FINAL 16 Oct 2008
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Wrong site surgery and the Protocol 2 Review of implementation of Ensuring Correct Patient, Correct Site, Correct Procedure Protocol in surgery 2. Wrong site surgery and the Protocol Wrong site surgery was one of the first areas in which patient identification errors were identified. In 1998, the Joint Commission, the leading accreditation ...
[PDF File]PDF Preparing the Patient for Surgery - Jones & Bartlett Learning
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Identify at least eight factors that may contribute to wrong-site surgery. 6. Describe the three components of the Joint Commission protocol to prevent wrong-site surgery. 7. Discuss the content of preoperative patient teaching. P 13 2 -RQHV %DUWOHWW/HDUQLQJ //& 127)256$/(25',675,%87,21
[PDF File]PDF 2008 This Issue: Wrong Site Surgery - United States Army
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This case illustrates the perils of wrong site surgery and the need for accurate and indelible surgical mark-ings. Wrong site surgery events can result in catastrophic outcomes for the patient and have an adverse impact on health-care professionals and institutions. This Focused Review analyzes DoD wrong site surgery RCAs and suggests risk re-
[PDF File]PDF Clinical Alert - Maryland Department of Health
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Lest anyone think that the issue of wrong site procedures and retained foreign bodies has bypassed Maryland, or that we have found solutions in our state to these vexing and preventable problems, we present the follow-ing cases of adverse events that occurred in the operating rooms of Maryland hospitals. These six cases of wrong site surgery were
[PDF File]PDF Wrong Site Surgery storyboard
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Wrong Site Surgery? Everyone agrees that wrong site surgery is a serious preventable adverse event. It should never happen. Although reporting is not mandatory in most states, some estimates put the national incidence rate, which includes wrong patient, wrong procedure, wrong site, and wrong side surgeries, as high as 40 per week.
[PDF File]PDF Wrong-Site, Wrong-Sided, Wrong Patient, Wrong Procedure Surgery
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Wrong-site surgery Never before had such a strong national emphasis been placed on the need for surgical site marking and a preoperative verification process as major components of a systems solution to help eliminate the incidence of wrong-site, wrong-patient, wrong-procedure surgery
[PDF File]PDF Two Cases of a Wrong-Site Peripheral Nerve Block and a ...
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Conclusions: The anesthesiologist plays an important role in preventing wrong-site peripheral nerve block-ade and surgery. The protocol developed for "Pre-Anesthetic Site Verification" as a supplement to our preop-erative site verification policy is invaluable in preventing wrong-site anesthesia and surgery. Reg Anesth Pain Med 2005;30:99 ...
[PDF File]PDF Quality and safety
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New case study details wrong-site surgery safety strategies. A new, free educational tool from The Joint Commission details ways to identify risk factors and possibly improve processes related to wrong-site surgery. Case Example #2: Patient Undergoes Additional Procedure After Wrong Lung Biopsy is a fictionalized study of conditions
[PDF File]PDF Focusing on Eye Surgery
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Case Studies in Wrong-Side Procedures Case #1—In this well documented report, a pa-tient undergoing surgery was asked to identify the operative site, which the scrub nurse marked with an "X" above the eye. A physician finished the surgical prep and draped the site. Several mem-bers of the surgical team verified the operative
[PDF File]PDF Patient Identification Errors - ECRI Institute
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causes of patient identification errors and identifies effective interventions for decreasing wrong-patient mistakes. ... protect information from degradation. Notably, one Canadian study found that during surgery, wristbands were ... wrong-patient orders.5 The relative simplicity of these ...
[PDF File]PDF Preventing Wrong-Patient, Wrong-Site, Wrong- Procedure Events
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Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure Events POSITION STATEMENT AORN is dedicated to the promotion of safe, optimal outcomes for patients undergoing operative and other invasive procedures. AORN recognizes the need to implement standardized processes developed by safety,
PDF Universal Protocol for Preventing Wrong Site, Wrong Procedure ...
In the case of multiple sides/sites during the same procedure, each side and site must be marked. ... - Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery and Guidelines for Implementing the Universal Protocol -
[PDF File]PDF PAPER Incidence, Patterns, and Prevention of Wrong-Site Surgery
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tics, and causes of wrong-site surgery and characteris-tics of site-verification protocols. Results: Among 2826367 operations at insured insti-tutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112994 operations (95% confidence interval, 1in76336to1in174825).Medicalrecordswereavail-
[PDF File]PDF Safe Surgery in Australian Hospitals: Implementation of The ...
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'That all public hospitals will adopt the 5 step right patient, right site, right procedure protocol for verifying the site of surgery and other procedures to reduce the risk of wrong site procedures by the end of September 2004' (Department of Health and Ageing 2004).
[PDF File]PDF NOT RECOMMENDED FOR FULL-TEXT PUBLICATION File Name: 19a0488n
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reason for reducing his surgical privileges: the unchallenged reality of serial wrong-site eye surgeries. Ahad, by the way, disputes whether the 2001 incident counts as a wrong-site surgery. Even so, he admits that he operated on the wrong eyes in 2005 and 2008. Those two mishaps by themselves suffice to resolve the case.
[PDF File]PDF Facility name: Date - Patient Safety Authority
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successful use for capturing information about wrong-site surgery, near misses, and actual occurrences in Pennsylvania. Anyone faced with a wrong-site surgery near miss or occurrence in his or her facility is encouraged to use this form to aid in the analysis. Extent of Error: (select the description most representative of the event)
[PDF File]PDF Surgical Safety: Addressing the JCAHO Goals for Reducing ...
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Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events Sandra Ludwick Abstract Under standards set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), health care facilities are required to implement established patient safety goals.
WHO Guidelines for Safe Surgery 2009
The safe surgery saves lives approach 5 Improvement through the safe surgery saves lives programme 5 Organization of the guidelines 7 Section II. Ten essential objectives for safe surgery: review of the evidence and recommendations 9 Objective 1: The team will operate on the correct patient at the correct site 10 The universal protocol 11
[PDF File]PDF errors
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objects removed. In one case, a signet ring was removed from Douglas's pouch. 5 Today, surgical sponges, instruments, towels and suture needles make up the bulk of objects retained during sur gical procedures. In many of these cases, counts were documented as correct at the time. Wrong-site or wrong-sided surgery is another
[PDF File]PDF Department Of Health Medical Quality Assurance Commission ...
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preventing wrong site surgery recommended by the Joint Commission, the American College of Surgeons or other appropriate national organizations. C. The preparation of a typed paper on the topic of wrong site surgery, including how Respondent has implemented changes into his or her practice to prevent the event from re-occurring. D.
Reducing the Risks of Wrong Site Surgery Using the Joint ...
insurers have decided to no longer pay providers for WSS or wrong-person surgery, or for leaving a foreign object in a patient's body after surgery. Surgery performed on the wrong site or wrong person has often been held compensable under malpractice claims. In fact, "84% of wrong-site orthopedic and 79% of wrong-site eye surgery claims
[PDF File]PDF Case Example #2 Patient undergoes additional procedure after ...
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Case Example #2. Patient undergoes additional procedure after wrong lung biopsy. Safety Strategy: A multidisciplinary team analyzed the Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Patient Surgery™ for practices, upstream scheduling processes, and other conditions (e.g., room access,
[PDF File]PDF Appendix. Details of the Wrong-Site Surgery Cases in Table IX
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Details of the Wrong-Site Surgery Cases in Table IX Wrong-Site Regional or Local Anesthesia ... no additional information was provided about this case. Wrong Digit(s) Three patients had the intended procedure performed on the wrong digit(s). One
[PDF File]PDF Prevention of Wrong Site Surgery, Retained Surgical Items ...
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Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires Evidence-based Synthesis Program. 9. CONTENTS. 34. PREFACE. Quality Enhancement Research Initiative's (QUERI) Evidence-based Synthesis Program
[PDF File]PDF 2 The Willie King Case: Wrong Foot Amputated Cause Mapping
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case occurred to help reduce the risk of wrong site surgery. Surgeons in Florida are now required to take a timeout prior to beginning a surgery. During the time out they are required to confirm that they have the right patient, right procedure and right surgical site. This rule has been in place since 2004. In one of the most notorious medical ...
[PDF File]PDF Reducing the Risks of of Wrong-Site Surgery
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Although rare and difficult to study, wrong-site surgery is a serious risk recognized by health care organizations. Health care organizations in a variety of settings, from small to large and from rural to urban, both teaching and nonteaching, must manage the risks of wrong-site surgery to ensure the safety of patients.
PDF Number 464 • September 2010 (Replaces No. 328, February 2006 ...
increased risk of wrong-site surgery: • Multiple surgeons involved in the case • Multiple procedures during a single surgical visit • Unusual time pressures to start or complete the pro-cedure • Unusual physical characteristics, including morbid obesity or physical deformity A common theme in cases of wrong-site surgery
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