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Statement on Preventing Wrong Side Procedures

WAKE UP SAFE, a component organization of the Society for Pediatric Anesthesia, is a newly formed Patient Safety Organization, listed by the Agency for Healthcare Research and Quality, and partially supported by the Anesthesia Patient Safety Foundation and ten founding pediatric institutions. The goal of WAKE UP SAFE is to create a registry of significant adverse events that occur during pediatric anesthesia, to learn from the events, and to disseminate suggestions for improvement. 

Five cases of wrong side procedure were recently submitted to the WAKE UP SAFE registry. These events all occurred during the year 2008.  There were two wrong side regional blocks and three wrong side surgical procedures. Even though the registry was not yet fully functional in 2008, the approximate yearly case total was 145000 for the institutions reporting, thus the incidence of wrong side procedures among the reporting institutions was 1/29000 anesthetics. Although the incidence seems high, there is also a high incidence of wrong side surgery and blocks reported in Pennsylvania1, and also in the United Kingdom2,3.
The reports indicate that for the wrong side blocks there was no formal “time out” prior to the block. For the surgical procedures, although the universal protocol was in place, it was not strictly followed.  Several protocol violations were noted, including the side of the procedure not indicated on the consent, the site marking not visible after the patient was prepped and draped, and failure to display appropriate images.

After review of these cases the following points can be made:

  1. Wrong side procedures can and do occur in major pediatric hospitals.

  2. A formal “time out” is necessary prior to regional anesthesia procedures.

  3. Having a universal protocol for procedures is not enough. The protocol must be followed. Failure to follow protocol is a common problem in the Pennsylvania reports4.

  4. Teamwork among nurses, anesthesiologists and surgeons is an important component in preventing wrong side procedures.

References:

  1. http://www.patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/
    Pages/psrs_qreports.aspx
    . Accessed August 11, 2009.

  2. http://www.npsa.nhs.uk/nrls/. Accessed Aug 11, 2009

  3. Shinde S, Carter JA. Wrong side neurosurgery-still a problem. Anaesthesia 2009, 64, pp 1-2. 

  4. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Jun6(2)/
    Pages/69.aspx
    . Accessed Aug 11, 2009