"Eye surgeon’s error confounds boy’s parents. She mistakenly operated on the wrong one; lawsuit being mulled." Read more at The Columbian.
Don't wait till a catastrophe happens.
Wrong site surgery (WSS) events are often devastating to the patient, nursing staff, surgeon, and facility where the surgery was performed. When they occur, it is common practice to perform root cause analysis to determine the causes of or factors that contributed to the accident. There's a safer way to get better though.
Near misses, sometimes referred to as close calls or potential adverse events, are defined as acts of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention or mitigation. (Bates 1995). Near miss analysis is the review of types and causes of error and an investigation of how those errors were mitigated. This type of analysis can contribute towards preventing never events, such as WSS. (National Academy of Sciences 2004)
As a surrogate for WSS, analysis of near miss events may allow organizations to examine the effectiveness of complex systems designed to prevent WSS, without such an event ever occurring. (Yoon 2015) A system to capture and analyze near miss data would present a substantial opportunity to reduce or eliminate WSS.
An evaluation of 487 orthopedic surgery procedures with the StartBox System identified 17 near miss events that could have led to the occurrence of a wrong-site surgery. The use of the System resulted in the occurrence of zero wrong site surgeries.