Surgical case listing accuracy: failure analysis at a high-volume academic medical center

Archives of Surgery
Robert R CimaClaude Deschamps

Abstract

Describe the incidence, type, and detection method of surgical listing errors and implement a system to reduce errors. All errors/discrepancies between the surgical listing and the performed procedure reported to an institutional event line during 2008 were analyzed. Academic tertiary medical center. Error characteristics and detection mode were documented. An error causal tree analysis was developed and used to modify the standard listing process to reduce errors. During 2008, 759 listing errors were reported of 55 197 surgical procedures for an error rate of 1.38%. No wrong-site surgeries occurred. The errors were missing laterality (501; 66%), incorrect side (108; 14%), incorrect listing besides laterality (86; 11%), and other (64; 9%). Identification/correction of the listing error occurred in the following areas: nursing review the evening prior to surgery (517; 68%), preoperative admission unit (132; 17%), operating room (98; 12%), recovery room (6; 0.8%), and other (6; 0.8%). Using a causal tree analysis, error-proofing strategies applied in an electronic standardized case listing system significantly reduced the error rate from 1.50% to 0.54% (P < .05) and 2.06% to 0.49% (P < .05) in gynecologic and colorectal surgery, ...Continue Reading

Citations

May 3, 2011·Journal of Neurosurgery·David Cochrane
Nov 4, 2016·American Journal of Medical Quality : the Official Journal of the American College of Medical Quality·Joseph J PariserAlexander Langerman
Oct 4, 2014·The Journal of Surgical Research·Zachary A AbecassisSanjay Mehrotra
Feb 26, 2015·Journal of Digital Imaging·Young Han LeeJin-Suck Suh
Jun 5, 2015·Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality·Erin M FairchildSunanda V Kane
Dec 4, 2020·Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine·Yan-Fen ZhangFen-Sui Li
Sep 27, 2012·American Journal of Surgery·Rebecca L Wu, Arthur H Aufses
Feb 25, 2017·Journal of Patient Safety·Donna S WatsonKenn B Daratha
Jul 20, 2010·American Journal of Surgery·Hiram C PolkSusan Galandiuk

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