title: Applying fault tree analysis to the prevention of wrong-site surgery.
abstract: Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Electronic address: Zacharyabecassis2011@u.northwestern.edu.
authors.forename: Zachary A
authors.initials: ZA
authors.lastname: Abecassis
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: McElroy
authors.affiliation: Division of Sports Medicine, Illinois Bone and Joint Institute, LLC, Morton Grove, Illinois.
authors.forename: Ronak M
authors.initials: RM
authors.lastname: Patel
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Rebeca
authors.initials: R
authors.lastname: Khorzad
authors.affiliation: Department of Orthopaedic Surgery, NOI NorthShore Orthopedics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Charles
authors.initials: C
authors.lastname: Carroll
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Mehrotra
mesh_terms: D001071:Appointments and Schedules; D019091:Critical Pathways / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007430:Intraoperative Care / Q000592:standards* / Q000706:statistics & numerical data; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data; D011300:Preoperative Care / Q000592:standards* / Q000706:statistics & numerical data; D011336:Probability; D015203:Reproducibility of Results; D018570:Risk Assessment; D013043:Specialties, Surgical / Q000592:standards* / Q000706:statistics & numerical data
keywords: Fault tree analysis; Medical errors; Preoperative process; Probabilistic risk assessment; Scheduling; Wrong-site surgery