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

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

JAMA Surg. 2014 Aug;149(8):774-9

Authors: Miller KE, Mims M, Paull DE, Williams L, Neily J, Mills PD, Lee CZ, Hemphill RR

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 [PubMed - indexed for MEDLINE]

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