
<oai_dc:dc xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:oai_dc="http://www.openarchives.org/OAI/2.0/oai_dc/" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://www.openarchives.org/OAI/2.0/oai_dc/ http://www.openarchives.org/OAI/2.0/oai_dc.xsd">
  <dc:title>Wrong-site orthopedic operations on the extremities : the Pennsylvania experience</dc:title>
  <dc:title>Pennsylvania patient safety advisory</dc:title>
  <dc:creator>Clarke, John R. author.</dc:creator>
  <dc:subject>Extremities -- surgery</dc:subject>
  <dc:subject>Medical Errors -- statistics &amp; numerical data</dc:subject>
  <dc:subject>Orthopedic Procedures -- statistics &amp; numerical data</dc:subject>
  <dc:description>The Pennsylvania Patient Safety Authority analyzed 83 wrong-site extremity procedures within the domain of orthopedic surgery reported over a nine-year period, representing 15% of the 541 reports of wrong-site operating room procedures in Pennsylvania hospitals and ambulatory surgical facilities from July 2004 through June 2013. The most common body parts involved were the hand (6% of all 541 reports), the knee (5%), and the foot (3%). All 34 wrong-site hand procedures were initiated at the wrong site on the correct hand; 12 involved operating on an adjacent finger, and 9 involved making an incision for a carpal tunnel release instead of an intended trigger finger release. Most (92%) of the 25 wrong-site knee procedures were performed on the wrong knee. The 14 wrong-site foot procedures were a mix of both the wrong foot and the wrong site on the correct foot. Overall, 18 wrong-site procedures on the legs involved the injection of local anesthetic into the knee joint or foot at the beginning of the procedure; 13 of them were done without the benefit of a proper time-out. The following marking and time-out practices might have prevented specific types of wrong-site extremity procedures: (1) mark the site close to the planned incision and reference it during all steps leading up to the incision, and (2) do separate time-outs for separate procedures on the same patient.</dc:description>
  <dc:publisher>[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, March 2015</dc:publisher>
  <dc:contributor>Pennsylvania. Patient Safety Authority, issuing body.</dc:contributor>
  <dc:contributor>ECRI (Organization), issuing body.</dc:contributor>
  <dc:contributor>Institute for Safe Medication Practices, issuing body.</dc:contributor>
  <dc:type>Technical Report</dc:type>
  <dc:format>Text</dc:format>
  <dc:format>1 online resource (1 PDF file (pages 19-27)).</dc:format>
  <dc:identifier>nlm:nlmuid-101655451-pdf</dc:identifier>
  <dc:identifier>101655451</dc:identifier>
  <dc:identifier>http://resource.nlm.nih.gov/101655451</dc:identifier>
  <dc:language>English</dc:language>
  <dc:coverage>Pennsylvania</dc:coverage>
  <dc:coverage>United States</dc:coverage>
  <dc:rights>Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. https://creativecommons.org/licenses/by-nc-nd/3.0</dc:rights>
</oai_dc:dc>