Increase Noted in Reported Wrong-Site Surgery Events From Interventional Radiology
Wrong-site surgery (WSS) is a well-known type of medical error that continues to occur in healthcare facilities. Wrong-site surgery involves all surgical procedures performed on the wrong patient, wrong body part, wrong side of the body, or wrong site, including wrong level of a correctly identified anatomic site.
The National Quality Forum (NQF) defines surgery as “an invasive operative procedure in which skin or mucous membranes and connective tissue is incised or an instrument is introduced through a natural body orifice. Surgery begins, regardless of setting, at the point of surgical incision, tissue puncture, or the insertion of an instrument into tissues, cavities, or organs.”
Research published by the Patient Safety Authority (PSA) revealed that on average 1.42 WSS events occur per week in Pennsylvania. While it is true that a majority of WSS events occur in perioperative areas, a steady number of these events arise outside of the operating room (OR) in areas such as interventional radiology (IR).
In our December 2020 study published in Patient Safety, research found that the “frequency of WSS was consistently greater in the hospital OR than IR; nevertheless, IR experienced a range of 6 to 13 WSS events per year, over the five-year period.”
Ongoing research into reported WSS events has revealed an alarming finding. For the period January 1, 2023, through March 31, 2023, there were eight WSS events originating from IR. These reported WSS events (examples below) included wrong-site, wrong-side, and wrong-procedure cases. The number of IR WSS cases in the first quarter of 2023 was the highest quarterly total since 2015.
“A patient goes to IR for nephrostomy tube placement. Upon return to the inpatient unit, it is realized that the tube was placed on the wrong side. The patient returns for the correct tube placement the following day.”
“… patient with a compression fracture of T-12 vertebra … underwent a kyphoplasty in IR … after reviewing CT results, MD discovered the T-12 fracture remained with kyphoplasty being performed on T-11 …”
In 2008, the Standards of Practice Committee of the Society of Interventional Radiology released the current “Quality Improvement Guidelines for Preventing Wrong Site, Wrong Procedure, and Wrong Person Errors: Application of The Joint Commission ‘Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery’ to the Practice of Interventional Radiology.” These guidelines supplement The Joint Commission Universal Protocol, and the PSA/Pennsylvania Department of Health Final Recommendations to Ensure Correct Surgical Procedures and Correct Nerve Blocks.
We encourage facilities to review/revise their Universal Protocol policies and procedures and monitor for compliance to decrease the likelihood of a future WSS event both in perioperative areas and interventional medicine departments.
Click here to see how interventional radiology events are reported into the Pennsylvania Patient Safety Reporting System (PA-PSRS) using the reporting decision tree.