Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences.
OBJECTIVE
To determine the frequency, root cause, and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol.


METHODS
Analysis of a prospective physician insurance database performed from January 1, 2002, to June 1, 2008. Deidentified cases were screened using predefined taxonomy filters, and data were analyzed by evaluation criteria defined a priori.


METHODS
Colorado.


METHODS
Database contained 27 370 physician self-reported adverse occurrences.


METHODS
Descriptive statistics were generated to examine the characteristics of the reporting physicians, the number of adverse events reported per year, and the root causes and occurrence-related patient outcomes.


RESULTS
A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a "time-out" (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.


CONCLUSIONS
These data reveal a persisting high frequency of surgical "never events." Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.
Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 80204, USA. philip.stahel@dhha.org
Philip F
PF
Stahel
Allison L
AL
Sabel
Michael S
MS
Victoroff
Jeffrey
J
Varnell
Alan
A
Lembitz
Dennis J
DJ
Boyle
Ted J
TJ
Clarke
Wade R
WR
Smith
Philip S
PS
Mehler
D003120:Colorado; D005260:Female; D006801:Humans; D016365:Liability, Legal; D008297:Male; D008318:Malpractice; D019300:Medical Errors / Q000331:legislation & jurisprudence / Q000517:prevention & control / Q000706:statistics & numerical data*; D016749:National Practitioner Data Bank; D012189:Retrospective Studies; D012308:Risk Management; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000331:legislation & jurisprudence; D014481:United States