Paull Douglas E, Mazzia Lisa M, Neily Julia, Mills Peter D, Turner James R, Gunnar William, Hemphill Robin
VA National Center for Patient Safety - Ann Arbor, Ann Arbor, MI, USA.
VA National Center for Patient Safety - Ann Arbor, Ann Arbor, MI, USA.
Am J Surg. 2015 Jul;210(1):6-13. doi: 10.1016/j.amjsurg.2014.10.030. Epub 2015 Mar 21.
The Universal Protocol has been associated with the prevention of wrong surgery procedures; however, such events still occur. This article explores wrong surgery events, defined as those incorrect procedures (wrong site, wrong side, wrong procedure, wrong patient, wrong level, wrong implant) that would have occurred despite the Universal Protocol including the performance of a time-out by the surgical team. Understanding why some of these events are not caught by the steps of the Universal Protocol, culminating in the time-out, can help the field to add upstream and downstream safeguards to help prevent these never events.
The Veterans Health Administration database of root cause analyses was queried for all cases involving an incorrect surgical procedure between 2004 and 2013 to determine the relative frequency and characteristics of wrong surgery events because of errors upstream and downstream to the Universal Protocol. This subgroup of wrong surgery events was selected from among all the wrong surgery events by 2 clinicians with expertise in patient safety (Kappa = .91).
Forty-eight cases of wrong surgery events because of upstream/downstream errors were analyzed, representing 16% of the 308 root cause analyses for wrong surgery events reported during this period. Upstream errors included mislabeling of specimens, while downstream errors were associated with ineffective intraoperative process. Surgical procedures that were particularly vulnerable included wrong level spine operations, wrong patient prostatectomies, wrong implant cataract procedures, and wrong site skin lesion excisions.
Wrong surgery events can and do occur despite adherence to Universal Protocol including a time-out. The prevention of incorrect procedures requires complementary safety behaviors and technologies to address errors that occur upstream and downstream to the Universal Protocol and the time-out.
《通用协议》与预防手术程序错误相关联；然而，此类事件仍有发生。本文探讨手术错误事件，即那些即便实施了《通用协议》（包括手术团队进行暂停核查）仍会发生的不正确程序（手术部位错误、手术侧别错误、手术操作错误、患者错误、手术节段错误、植入物错误）。了解为何这些事件中的一些未被《通用协议》的步骤（最终是暂停核查）发现，有助于该领域增加上游和下游保障措施，以预防这些严重不良事件。
查询退伍军人健康管理局的根本原因分析数据库，获取2004年至2013年期间所有涉及不正确手术程序的病例，以确定《通用协议》上下游错误导致的手术错误事件的相对频率和特征。这一手术错误事件亚组由两名患者安全领域的专家从所有手术错误事件中挑选出来（卡帕值 = 0.91）。
分析了48例因上下游错误导致的手术错误事件，占该时期报告的308例手术错误事件根本原因分析的16%。上游错误包括标本标记错误，而下游错误与术中流程无效有关。特别容易出现错误的手术程序包括脊柱节段错误手术、患者错误的前列腺切除术、植入物错误的白内障手术以及手术部位错误的皮肤病变切除术。
尽管遵循了包括暂停核查在内的《通用协议》，手术错误事件仍有可能且确实会发生。预防不正确程序需要补充安全行为和技术，以解决《通用协议》及暂停核查上下游出现的错误。
