Pennsylvania’s Patient Safety Authority Releases Data on Wrong-Site Surgeries and Results From a Hospital Pharmacy Computer System Safety Study
MedSun: Newsletter #16, July 2007

The June 2007 Patient Safety Advisory published by the Pennsylvania Patient Safety Authority (PSA) presented data on wrong-site surgery indicating that in a 30-month period—June 2004 through December 2006—PSA received reports of 427 near misses and serious events of wrongsite surgeries. Of those, 253 were near misses or did not reach the patient. Of the wrong-site surgeries, 69 percent were on the wrong side, 14 percent were on the wrong body part, 9 percent were the wrong procedure, and 8 percent were on the wrong patient. The most common sites for wrong-site surgery were extremities, the eyes, and the spine. The most common wrong-site procedures were orthopedic and ophthalmologic surgeries.

Risk factors for wrong-site surgery include multiple procedures and/or multiple surgeons; communication breakdowns; time pressures; incomplete preoperative assessments; and organizational cultural factors unconducive to promoting teamwork, such as an attitude that surgeons’ decisions should never be questioned. In many cases, the patient or a family member was responsible for providing information that prevented the wrong-site surgery.

Dr. Stan Smullens, chief medical officer of the Jefferson Health System and vice president of the PSA Board of Directors stated, “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. 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.” This summer, PSA will begin to gather comprehensive information on which to base new, more effective guidance to help facilities prevent wrong-site surgeries.

The PSA May 2007 Supplementary Advisory featured results from the Pennsylvania Patient Safety Reporting System assessment by a Workgroup on Pharmacy Computer System Safety of safety features and capabilities of hospital pharmacy computer systems. Findings from this study, which was carried out on a voluntary basis by creating fictitious patient profiles and 18 unsafe medication orders in 30 Pennsylvania hospitals, showed that the pharmacy computer systems failed to identify harmful interactions and overdoses and also allowed users to override serious warnings that put patients at risk.

“Many of the systems performed poorly when tested with specific unsafe medication orders to assess their ability to detect serious or fatal errors they reported to us. None of the 30 systems tested in the workgroup [was] able to detect all unsafe orders presented in the field test, and one system only detected one unsafe order,” said Mike Doering, PSA interim executive director. Doering encourages all facilities to test their pharmacy computer systems more frequently to ensure they are using the error-catching features to their full potential and to ensure that the systems are capable of preventing such errors.

“New or updated technology is part of the solution to reducing the risk of error, but there is always a danger of relying too much on technology as a safety net,” added Doering. “Pharmacists should not rely on this tool alone to detect potentially harmful medication errors. They should work with staff and communicate problems on a regular basis to prevent future errors.”

To read the full articles on these investigations, go to, click on “Advisories and Related Resources,” and then scroll down to “Doing the ‘Right’ Things To Correct Wrong-Site Surgery” in the June 2007 Advisory, and “Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety” in the May 2007 Supplementary Advisory.

Additional Information:

Doing the ‘Right’ Things To Correct Wrong-Site Surgery

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