According to the Pennsylvania Patient Safety Authority (PSA), 57 wrong-site surgeries took place in Pennsylvania between July 1, 2009, and June 30, 2010. The Joint Commission reports that the national average is 40 per year.
In 2004, the Joint Commission attempted to address this patient safety issue with a universal protocol for wrong-site surgery. Since that time, wrong-site surgeries have actually increased according to PSA data.
To avoid future wrong-site surgeries, physicians can play a key role by cultivating a team approach and removing the intimidation that accompanies the hierarchy in a surgical suite. Traditional top-down management skills do not encourage team members to speak up when they see a problem.
Physician leadership can create the positive environment needed to prevent the next wrong-site surgery. While it is necessary for physicians to be the quick decision makers, intimidation must be removed, according to Martin A. Markey, MD, associate professor of surgery at John Hopkins University School of Medicine.
“Ideally, the surgeon should initiate a time-out process during a pause in operative preparations. This often occurs immediately before the incision when all team members are focused on the time-out process,” said John J. Pagan, MD, a general surgeon and chair of the Pennsylvania Medical Society’s Board of Trustees.
“Physicians should take steps to encourage all surgical team members to stay engaged throughout the entire time-out process to be sure the patient, surgical site, and patient position are correct before surgery begins,” said Dr. Pagan.