Pennsylvania Healthcare Facilities Successfully Implement Wrong-Site Surgery Best Practices

PR Newswire

The twenty-one wrong-site surgery potential recommendations are seen by surveyed facilities as achievable with some modifications

HARRISBURG, Pa., Nov. 20, 2012 /PRNewswire-USNewswire/ -- More than 30 percent of Pennsylvania healthcare facilities have successfully implemented 21 potential recommendations for preventing wrong-site surgery, according to the November supplementary Pennsylvania Patient Safety Advisory released today.

The Pennsylvania Patient Safety Authority sent 417 Pennsylvania facilities with operating rooms its 21 potential recommendations to prevent wrong-site surgery. The Authority asked the facilities to describe barriers for implementing the recommendations that would prevent them from meeting the standard or standards for the goal.

The Authority survey divided the 21 potential recommendations into five groups, with a total of six goals and eight proposed measurement standards for the groups. For each of the six goals the Authority asked facilities to describe barriers for successful implementation. Seventy facilities responded to the survey. Two-thirds of the responses were from hospitals, and one-third were from ambulatory surgical facilities.

"Overall, the surveyed Pennsylvania healthcare facilities felt they could successfully implement the potential recommendations for preventing wrong-site surgery," Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority said. "Less than twenty percent of surveyed healthcare facilities identified some barriers to implementation, but all of the barriers could be modified or overcome through education, policy changes or culture changes."

Pennsylvania healthcare facilities responding to the survey gave their reasons for successful implementation of the 21 potential recommendations to prevent wrong-site surgery.

"Education, audits, leadership and empowerment of nurses to 'stop the line' were some of the strategies facilities cited they have used to successfully implement wrong-site surgery best practices," Clarke said. "Elaboration of these strategies includes leadership buy-in from surgery departments and respectful interactions with staff."

Clarke added that 27 facilities commented about the feasibility and potential cost impact of implementing the potential recommendations associated with each of the eight standards.

"Most respondents—20 out of 27—had no concerns, indicating that the potential recommendations were in place or that they thought implementation was feasible at minimal cost," Clarke said. "Seven expressed primarily cost concerns."

Clarke said concerns about potential cost impact include: personnel time to verify and reconcile information, resources to monitor compliance, personnel time for redundant checking of information, resources needed to implement the evidence-based best practices, resources and time for education, resources to upgrade electronic and paper documents, possible increased staffing, OR delays and loss of business and physician availability on-site or remotely for a second verification of intraoperative images.

"Each of these concerns is addressed by the Authority in the Supplementary Advisory," Clarke said. "This survey is another piece of the puzzle needed to increase our efforts to prevent wrong-site surgeries in Pennsylvania. The facilities who responded to the survey have helped us focus more intently on what works and what doesn't."

Clarke added that physician behavior and accessing accurate information before the patient's arrival in the preoperative holding area were cited by surveyed Pennsylvania healthcare facilities as common barriers.

Another article in the November supplementary highlights comments made from Pennsylvania medical professional societies on the Authority's 21 potential recommendations to prevent wrong-site surgery.

For more information about wrong-site surgery, comments about the 21 potential recommendations and the survey, go to the November supplementary Patient Safety Advisory on the Authority's website at


The Patient Safety Authority's program to prevent wrong-site surgery began in December 2007 after an Advisory article revealed that Pennsylvania healthcare facilities were submitting approximately two and a half wrong-site surgery reports (Serious Events and near misses) per week.

Since the prevention program began, wrong-site surgeries in Pennsylvania have decreased by 37 percent from an average of 19 reports per quarter to an average of 12 reports per quarter. The Authority's wrong-site surgery prevention program has garnered its own webpage with 20 Advisory articles, 13 prevention program tools, seven educational tools (e.g., brochures, presentations) and 11 snapshots that include wrong-site surgery breakdown reports and key best practice principles.        

In April the Authority began another wrong-site surgery initiative with 28 Pennsylvania healthcare facilities that have made the commitment to reduce and eliminate wrong-site surgeries. The initiative is led by the Authority as part of the Hospital and Healthsystem Association of Pennsylvania (HAP) Hospital Engagement Network (HEN) funded by the Centers for Medicare and Medicaid Services (CMS). The Authority will receive about $1.6 million of $5.2 million awarded to HAP through the federal contract with CMS. The Authority is using the federal funds for three statewide projects that include wrong-site surgery, falls and adverse drug events.

For more information about the wrong-site surgery project go to the Authority's website at

SOURCE Pennsylvania Patient Safety Authority

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