Applying fault tree analysis to the prevention of wrong-site surgery.

Journal Article (Journal Article)

Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.

Full Text

Duke Authors

Cited Authors

  • Abecassis, ZA; McElroy, LM; Patel, RM; Khorzad, R; Carroll, C; Mehrotra, S

Published Date

  • January 2015

Published In

Volume / Issue

  • 193 / 1

Start / End Page

  • 88 - 94

PubMed ID

  • 25277361

Pubmed Central ID

  • PMC4268435

Electronic International Standard Serial Number (EISSN)

  • 1095-8673

Digital Object Identifier (DOI)

  • 10.1016/j.jss.2014.08.062


  • eng

Conference Location

  • United States