From the Scottish Centre for Simulation & Clinical Human Factors.
Forth Valley Royal Hospital, Larbert.
J Patient Saf. 2020 Mar;16(1):79-83. doi: 10.1097/PTS.0000000000000426.
Wrong-site/side surgical "never events" continue to cause considerable harm to patients, healthcare professionals, and organizations within the United Kingdom. Incidence has remained static despite the mandatory introduction of surgical checklists. Operating theater list errors have been identified as a regular contributor to these never events. The aims of the study were to identify and to learn from the incidence of wrong-site/side list errors in a single National Health Service board.
The study was conducted in a single National Health Service board serving a population of approximately 300,000. All theater teams systematically recorded errors identified at the morning theater brief or checklist pause as part of a board-wide quality improvement project. Data were reviewed for a 2-year period from May 2013 to April 2015, and all episodes of wrong-site/side list errors were identified for analysis.
No episodes of wrong-site/side surgery were recorded for the study period. A total of 86 wrong-site/side list errors were identified in 29,480 cases (0.29%). There was considerable variation in incidence between surgical specialties with ophthalmology recording the largest proportion of errors per number of surgical cases performed (1 in 87 cases) and gynecology recording the smallest proportion (1 in 2671 cases). The commonest errors to occur were "wrong-side" list errors (62/86, 72.1%).
This is the first study to identify incidence of wrong-site/site list errors in the United Kingdom. Reducing list errors should form part of a wider risk reduction strategy to reduce wrong-site/side never events. Human factors barrier management analysis may help identify the most effective checks and controls to reduce list errors incidence, whereas resilience engineering approaches should help develop understanding of how to best capture and neutralize errors.
在英国，错误部位/侧手术“从未发生过的事件”仍然给患者、医疗保健专业人员和组织造成相当大的伤害。尽管强制性引入了手术核对表，但发病率仍然保持不变。手术室清单错误已被确定为这些从未发生过的事件的一个常见原因。该研究的目的是在一个单一的英国国民保健系统委员会中确定并从错误部位/侧清单错误的发生率中吸取教训。
该研究在一个为约 30 万人口提供服务的单一英国国民保健系统委员会中进行。所有手术室团队都系统地记录了在早晨手术室简介或核对表暂停期间发现的错误，作为委员会范围内质量改进项目的一部分。数据审查时间为 2013 年 5 月至 2015 年 4 月的 2 年期间，对所有错误部位/侧清单错误的事件进行了分析。
在研究期间未记录手术部位/侧手术错误。在 29480 例病例中发现了 86 例错误部位/侧清单错误（0.29%）。各手术专业的发病率差异很大，眼科记录的错误发生率最高（每 87 例手术中就有 1 例），妇产科记录的错误发生率最低（每 2671 例手术中就有 1 例）。最常见的错误是“错误侧”清单错误（62/86，72.1%）。
这是英国首次确定错误部位/侧清单错误的发生率。减少清单错误应成为更广泛的风险降低策略的一部分，以减少错误部位/侧从未发生过的事件。人为因素障碍管理分析可能有助于确定减少清单错误发生率的最有效检查和控制措施，而弹性工程方法应有助于了解如何最好地捕获和中和错误。
