“Wake up Safe”—Wrong Sided Cases Reported to Registry

by Donald C. Tyler, MD, MBA

Wake up Safe, a component organization of the Society for Pediatric Anesthesia (SPA), is a newly formed Patient Safety Organization (PSO), listed by the Agency for Healthcare Research and Quality (AHRQ), and partially supported by the Anesthesia Patient Safety Foundation (APSF). 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 registry. These events all occurred during the year 2008. There were 2 wrong side regional blocks and 3 wrong side surgical procedures. Although the registry was not yet fully functional in 2008, the approximate yearly case total was 145,000 for the institutions reporting; thus, the incidence of wrong side procedures among the reporting institutions was 1/29,000 anesthetics. Although the incidence seems high, there is also a high incidence of wrong side surgery and blocks reported in Pennsylvania,¹ and also in the United Kingdom.^2,3

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

References

1. Patient Safety Authority, Commonwealth of Pennsylvania. Pennsylvania patient safety authority wrong-site surgery reports by quarter. Available at: http://www.patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Pages/psrs_qreports.aspx. Accessed August 24, 2009.
2. National Patient Safety Agency. Putting patient safety first. London, United Kingdom. http://www.npsa.nhs.uk/nrls/. Accessed August 24, 2009.
3. Shinde S, Carter JA. Wrong site neurosurgery—still a problem. Anaesthesia 2009;64:1-2.
4. Quarterly update on the preventing wrong site surgery project. Pennsylvania Patient Safety Advisory, June 2009. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Jun6(2)/Pages/69.aspx. Accessed August 24, 2009.

Dr. Tyler is an associate Professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia and chair of the Quality and Safety Committee of the Society for Pediatric Anesthesia.