Risk factors for wrong-site surgery: A study of 1,166 reports of informed consent and schedule errors (31 July 2024)

Summary

This study used the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to explore patterns in consent and schedule errors at all hospitals and ambulatory surgical facilities (ASFs) in Pennsylvania over a four-year period. The authors also evaluated error reports for consent and schedule error subtypes: side, procedure, site and patient. Of the 1,166 event reports studied:

• 56% described a schedule error
• 34% had a consent error
• 10% involved both error types.

In the sample of reports, the frequency of error subtypes were ranked in the following sequence: side (69%), procedure (24%), site (4%) and patient (3%). The analysis also revealed similarities and differences in the distribution of error types and subtypes across hospitals and ASFs.