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[Avoidance of Wrong Site Surgery. Experiences by the Introduction of Measures for Quality Control and Patient Safety in a Surgical Casualty Hospital]

Overview
Journal Unfallchirurg
Date 2009 Jun 23
PMID 19543870
Citations 3
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Abstract

Wrong site surgery leads to substantial individual injury to the affected patient. Therefore, organizations such as the WHO, the Joint Commission International (JCI) and the Action Alliance Patient Safety (APS) have developed procedures for avoidance of wrong site surgery. This is based on the active incorporation of patients in the process of intervention identification. In this manner the disclosure to the patient, marking of the site of surgery, identification before induction of anesthesia and the team time out are documented in a checklist recommended by the APS before the operation begins. In the DRK Clinics in Berlin the procedure for avoidance of wrong site surgery was introduced before the second recertification by the JCI for implementation of the patient safety recommendations and compliance with the four stages documented in a standard form. For successful implementation all members of staff and in particular the heads of the clinics and departments must be actively involved in order to obtain the acceptance permanently and to ensure that wrong site surgery no longer occurs in the DRK Clinics Berlin.

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References
1.
Meinberg E, Stern P . Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003; 85(2):193-7. DOI: 10.2106/00004623-200302000-00002. View

2.
Clarke J, Johnston J, Finley E . Getting surgery right. Ann Surg. 2007; 246(3):395-403, discussion 403-5. PMC: 1959354. DOI: 10.1097/SLA.0b013e3181469987. View

3.
Canale S . Wrong-site surgery: a preventable complication. Clin Orthop Relat Res. 2005; (433):26-9. View

4.
Chassin M, Becher E . The wrong patient. Ann Intern Med. 2002; 136(11):826-33. DOI: 10.7326/0003-4819-136-11-200206040-00012. View

5.
Haynes A, Weiser T, Berry W, Lipsitz S, Breizat A, Dellinger E . A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009; 360(5):491-9. DOI: 10.1056/NEJMsa0810119. View