Risk Factors for Wrong-Site Surgery: A Study of 1,166 Reports of Informed Consent and Schedule Errors

Abstract

Background The accuracy of informed consent and procedural schedule are important components in a process for preventing wrong-site surgery. Methods In our study of a four-year period, we used the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to explore the occurrence of consent and/or schedule errors at all licensed hospitals and ambulatory surgical facilities (ASFs) in Pennsylvania. We also evaluated the reports for consent and schedule error subtypes: side, procedure, site, and patient. Results Over a four-year period, 1,166 event reports described a consent and/or schedule error, and 86% of the reports were from hospitals and 14% were from ASFs. Among the 1,166 reports, 56% described a schedule error, 34% had a consent error, and 10% involved both error types. In the sample of reports, the frequency of error subtypes were ranked in the following sequence: side (69%), procedure (24%), site (4%), and patient (3%). The analysis also revealed similarities and differences in the distribution of error types and subtypes across hospitals and ASFs. Conclusions Based on the results, it is evident that consent and schedule errors are issues across many healthcare facilities. The findings by error subtype (side, procedure, site, patient) show some similarity in distribution with previous studies of wrong-site surgery events. We recommend that readers review Table 4 and Table 5 for a brief literature review of risk factors for consent and schedule errors and strategies for preventing and detecting the occurrence of those errors, respectively.