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Surgery: patient mix-ups and wrong-site errors are preventable

The use of a safety checklist and the patient’s active involvement help avoid errors, in particular in communication and diagnosis prior to surgery.

American and British studies of surgery errors have shown that many patient mix-ups and wrong-site errors (which side to operate on, for example), with consequences that are often irreversible and dramatic, are preventable.

In an American study involving around 6000 doctors, more than 27 000 adverse events were reported between 2002 and 2008. Out of 25 patient mix-ups (confusion between patients of the same name, for example), 5 suffered severe adverse events, 8 patients suffered moderate consequences since the procedure was halted at the beginning, or suffered consequences that were not far-reaching. Following 107 wrong-site errors, 1 patient died, 38 suffered severe and 65 suffered moderate consequences.

Analysis of the causes highlighted verbal or written communication errors in particular, diagnosis errors, treatment errors often considered as "unnecessary", and errors of judgement. Non-implementation of final checks before surgery was noted in 72% of the wrong-site errors.

The World Health Organization (WHO) has developed a method involving a series of cross-checks, the "surgical safety checklist". This list aims to improve safety in the operating theatre, reduce surgical errors and improve communication and information sharing.

Checks prior to surgery help prevent errors when they are applied methodically and systematically, with the involvement of the patient to verify their identity and the surgery site, and in training healthcare professionals, especially in the sharing of verbal information.

©Prescrire 1 January 2013

"Prevention of wrong-site and wrong-patient surgical errors" Prescrire Int 2013; 21 (134): 14-16. (Pdf, subscribers only).
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