Michaels Robert K, Makary Martin A, Dahab Yasser, Frassica Frank J, Heitmiller Eugenie, Rowen Lisa C, Crotreau Richard, Brem Henry, Pronovost Peter J
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Ann Surg. 2007 Apr;245(4):526-32. doi: 10.1097/01.sla.0000251573.52463.d2.
Review the evidence regarding methods to prevent wrong site operations and present a framework that healthcare organizations can use to evaluate whether they have reduced the probability of wrong site, wrong procedure, and wrong patient operations.
Operations involving the wrong site, patient, and procedure continue despite national efforts by regulators and professional organizations. Little is known about effective policies to reduce these "never events," and healthcare professional's knowledge or appropriate use of these policies to mitigate events.
A literature review of the evidence was performed using PubMed and Google; key words used were wrong site surgery, wrong side surgery, wrong patient surgery, and wrong procedure surgery. The framework to evaluate safety includes assessing if a behaviorally specific policy or procedure exists, whether staff knows about the policy, and whether the policy is being used appropriately.
Higher-level policies or programs have been implemented by the American Academy of Orthopaedic Surgery, Joint Commission on Accreditation of Healthcare Organizations, Veteran's Health Administration, Canadian Orthopaedic, and the North American Spine Society Associations to reduce wrong site surgery. No scientific evidence is available to guide hospitals in evaluating whether they have an effective policy, and whether staff know of the policy and appropriately use the policy to prevent "never events."
There is limited evidence of behavioral interventions to reduce wrong site, patient, and surgical procedures. We have outlined a framework of measures that healthcare organizations can use to start evaluating whether they have reduced adverse events in operations.
回顾关于预防手术部位错误操作方法的证据，并提出一个框架，供医疗保健机构用于评估其是否降低了手术部位错误、手术程序错误和患者错误的发生概率。
尽管监管机构和专业组织在全国范围内做出了努力，但涉及错误手术部位、患者和手术程序的手术仍在发生。对于减少这些“绝不允许发生的事件”的有效政策，以及医疗保健专业人员对这些政策的了解或适当使用以减轻此类事件的情况，人们知之甚少。
使用PubMed和谷歌对相关证据进行文献综述；使用的关键词为手术部位错误、手术侧别错误、患者错误手术和手术程序错误。评估安全性的框架包括评估是否存在针对特定行为的政策或程序、工作人员是否了解该政策以及该政策是否得到适当使用。
美国矫形外科医师学会、医疗保健机构认证联合委员会、退伍军人健康管理局、加拿大矫形协会和北美脊柱协会已经实施了更高级别的政策或计划，以减少手术部位错误。目前尚无科学证据指导医院评估其是否拥有有效的政策，以及工作人员是否知晓该政策并适当使用该政策以预防“绝不允许发生的事件”。
关于减少手术部位、患者和手术程序错误的行为干预措施的证据有限。我们概述了一个措施框架，医疗保健机构可以使用该框架开始评估其是否减少了手术中的不良事件。
