Pennsylvania Patient Safety Authority News

Patient Safety Authority Supports 'National Time Out Day'

The Authority continues monitoring and evaluating wrong-site surgeries with the numbers remaining steady; releases preview of wrong-site surgery update

HARRISBURG, Pa., June 18 /PRNewswire-USNewswire/ — The Pennsylvania Patient Safety Authority today supports "National Time Out Day," which is a national effort to encourage surgical teams to "take time out" before every operation to confirm correct patient, correct procedure, correct surgical site and other important information to ensure patient safety and prevent wrong-site surgeries.

"The Authority continues to see wrong-site surgeries occurring in Pennsylvania facilities," Mike Doering, executive director of the Patient Safety Authority said. "To designate a specific day for time outs can only bring more awareness to a problem that we are continuing to monitor and evaluate as we work with facilities to improve results."

The Authority has published several Patient Safety Advisories about the issue since June 2007 in which data from the Pennsylvania Patient Safety Reporting System (PA-PSRS) showed that in a 30-month time period (June 2004 -December 2006) the Authority received 427 near miss and Serious Event reports of wrong-site surgeries in Pennsylvania. Of those, 253 were near misses or did not reach the patient.

Since the first wrong-site surgery Advisory the Authority has published quarterly updates from information received from facilities through site visits and supplementary questionnaires that detail what they've done to prevent wrong-site surgeries so that others can learn from their successes or failures. A webpage containing additional resources and guidance for facilities to prevent wrong-site surgeries is also available on the Authority's website at www.psa.state.pa.us. For consumers the Authority published a consumer tip sheet that is also available on its website.

The most recent update will be published in its June 2008 Patient Safety Advisory. The update preview details information the Authority received from questionnaires facilities answered after reporting a wrong-site surgery event.

"Facilities have invited us to come into their institutions and they've answered our questions in regard to their surgical protocols," Doering said. "The information allows us to give facilities more detailed guidance as to what appears to work for facilities and what doesn't."

Doering added that the compliance rate for answering the voluntary questionnaires has been 75 percent showing that facilities are working with the Authority to combat the problem.

"Through the questionnaires we are not only learning what can lead to a wrong-site surgery, but also what protocols work to avert patient harm," Doering said. "Our work to prevent wrong-site surgeries in Pennsylvania is a long-term effort."

"Facilities that have invited us into their institutions have helped us develop a keener insight into why wrong-site surgeries occur," Doering added. "We are currently recruiting more facilities to allow us to take a look at what they're doing so we can continue to learn from this ongoing problem that occurs not just in Pennsylvania, but nationally as well."

The June 18, 2008, National Time Out Day is sponsored by the Joint Commission, the Association of periOperative Registered Nurses (AORN) and the Council on Surgical and Perioperative Safety (CSPS).

For a copy of the wrong-site surgery update from the 2008 June Patient Safety Advisory, click http://www.psa.state.pa.us/psa/lib/psa/advisories/v5n2june_2008/jun_2008_v5_n2_article_update_wrong_site_surgery.pdf. For more information on the Patient Safety Authority, go to www.psa.state.pa.us.

SOURCE Pennsylvania Patient Safety Authority

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