Format

Send to

Choose Destination
JAMA Surg. 2014 Aug;149(8):774-9. doi: 10.1001/jamasurg.2014.146.

Wrong-side thoracentesis: lessons learned from root cause analysis.

Author information

1
Department of Veterans Affairs National Center for Patient Safety, Ann Arbor, Michigan.
2
Department of Veterans Affairs National Center for Patient Safety, White River Junction, Vermont.

Abstract

IMPORTANCE:

Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences.

OBJECTIVES:

To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with their occurrence.

DESIGN, SETTING, AND PARTICIPANTS:

We searched the National Center for Patient Safety database for wrong-side thoracenteses performed in ambulatory clinics and hospital units other than the operating room reported from January 1, 2004, through December 31, 2011.

MAIN OUTCOMES AND MEASURES:

Data extracted included patient factors, clinical features, team structure and function, adherence to bottom-line patient safety measures, complications, and outcomes.

RESULTS:

Fourteen cases of wrong-side thoracenteses are identified. Contributing factors included failure to perform a time-out (n=12), missing indication of laterality on the patient's consent form (n=10), absence of a site mark on the patient's skin within the sterile field (n=12), and absent verification of medical images (n=7). Complications included pneumothoraces (n=4), hemorrhage (n=3), and death directly attributable to the wrong-side thoracentesis (n=2). Teamwork and communication failure, unawareness of existing policy, and a deficit in training and education were the most common root causes of wrong-side thoracentesis.

CONCLUSIONS AND RELEVANCE:

Prevention of wrong-site procedures and accompanying patient harm outside the operating room requires adherence to the Universal Protocol and time-outs, effective teamwork, training and education, mentoring, and patient assessment for early detection of complications. The time-outs provide protected time and place for error detection and recovery.

PMID:
24920222
DOI:
10.1001/jamasurg.2014.146
[Indexed for MEDLINE]

Supplemental Content

Full text links

Icon for Silverchair Information Systems
Loading ...
Support Center