[Insight-users] Need help with orientation of images : Wrong-site surgery

[Luis Ibanez]

Hi John,

Here are some links that you may find interesting.

Probably the best reference is the one from JCAHO.
Notice that the percent in this case will be around
12% instead of 2%.


Regards,


    Luis


----------------------------------------------------

A) Report from the Institue of Medicine

    "To Err is Human: Building a Safer Health System"

         http://www.nap.edu/openbook/0309068371/html/


   "Based on the findings of one major study, medical errors kill some
    44,000 people in U.S. hospitals each year. Another study puts the
    number much higher, at 98,000. Even using the lower estimate, more
    people die from medical mistakes each year than from highway
    accidents, breast cancer, or AIDS."



B) from the Joint Commision on Accreditation of
Healthcare Organizations.

             http://www.jcaho.org/

    Statistics on causes of wrong site surgery
http://www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/rc+wrong+site+surgery.htm

    Statistics on number of wrong side surgery (reported)
http://www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/se_trends_wrgsite_events.htm
    Note that the scary aspect here is that
    most medical errors are unreported...

    Wrong side surgery events as a percent of reported
    medical errors.
http://www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/set+wrong+site+surgery.htm

    An overview of the events for which this organization
    collect statistics.
http://www.jcaho.org/accredited+organizations/office+based+surgery/sentinel+events/se_stats.pdf

    An HTML version is here.
http://www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/sentinel+event+statistics.htm

    Note that the percents are computed over the number
    of events collected and some of the events may not
    be what we considered "medical errors", for example:
    "patient suicice" which surprisingly accounts for 15%
    of the collected events.


    Here is the Universal Protocol for preventing wrong
    side surgery.
http://www.jcaho.org/accredited+organizations/patient+safety/universal+protocol/universal+protocol.pdf




C) From the Association of Operating Room Nurses
    http://www.aorn.org/about/positions/correctsite.htm



D) From the US Department of Veterans Affairs
    "Ensuring correct surgery" directive
    http://www.patientsafety.gov/CorrectSurgDir.pdf



E) From the American Academy of Orthopaedic Surgeons
    http://www.aaos.org/wordhtml/papers/advistmt/1015.htm
    (with a checklist protocol for preventing wrong side
     surgery).

    Report of the Task Force on Wrong-Site surgery
    http://www.aaos.org/wordhtml/meded/tasksite.htm


F) From the North American Spine Society
    http://www.spine.org/smax.cfm
    Prevention of Wrong-Site surgery


G) "Indicednce of wrong-site surgery among hand surgeons"
    J. Bone Joing Surg.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12571293&dopt=Abstract




--------------------------------------------------------------
John Biddiscombe wrote:

>>But.. this is *very* dangerous ! Note that 2% of the
>>(reported) medical errors in the US are "wrong side"
>>surgery. (e.g. operating on the left side instead of the
>>right side.). 
> 
> 
> Luis,
> 
> Do you have a source/reference for this comment? I'm responsible for
> making sure our images ar the right way round from various formats and
> I'd like to quote something this in some internal docs.
> 
> Any idea where I could find this mentioned that's referenceable.
> 
> Thanks
> 
> JB
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