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N E V E R
E V E N T S
DATA SAMPLING
Where and on Whom Wrong Events Are Happening
In "Quarterly Update: What Body Parts and Procedures Are Associated with Wrong-Site Surgery?" recently published in the Pennsylvania Patient Safety Advisory, which is issued by ECRI Institute and the Institute for Safe Medication Practices under contract to the Pennsylvania Patient Safety Authority, author John R. Clarke, MD, breaks down some of the common occurrences of wrong surgeries, using data from recent cases.
Wrong-Patient Events
• 4 involved patients with the same or similar names
• 2 involved another patient's information entered in the chart
• 1 involved using another patient's chart
• 1 involved operating on patients out of the scheduled order
Wrong-Procedure Events
• 14 hand procedures
• 12 insertions of an incorrect device, including 1 incorrect type of ear tubes
• 10 ENT procedures, including the previously noted ear tube event
• 5 eye procedures
Wrong-Location
