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

Publication ,  Journal Article
Abecassis, ZA; McElroy, LM; Patel, RM; Khorzad, R; Carroll, C; Mehrotra, S
Published in: J Surg Res
January 2015

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.

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Published In

J Surg Res

DOI

EISSN

1095-8673

Publication Date

January 2015

Volume

193

Issue

1

Start / End Page

88 / 94

Location

United States

Related Subject Headings

  • Surgery
  • Specialties, Surgical
  • Risk Assessment
  • Reproducibility of Results
  • Probability
  • Preoperative Care
  • Outcome and Process Assessment, Health Care
  • Medical Errors
  • Intraoperative Care
  • Humans
 

Citation

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ICMJE
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Abecassis, Z. A., McElroy, L. M., Patel, R. M., Khorzad, R., Carroll, C., & Mehrotra, S. (2015). Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res, 193(1), 88–94. https://doi.org/10.1016/j.jss.2014.08.062
Abecassis, Zachary A., Lisa M. McElroy, Ronak M. Patel, Rebeca Khorzad, Charles Carroll, and Sanjay Mehrotra. “Applying fault tree analysis to the prevention of wrong-site surgery.J Surg Res 193, no. 1 (January 2015): 88–94. https://doi.org/10.1016/j.jss.2014.08.062.
Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C, Mehrotra S. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res. 2015 Jan;193(1):88–94.
Abecassis, Zachary A., et al. “Applying fault tree analysis to the prevention of wrong-site surgery.J Surg Res, vol. 193, no. 1, Jan. 2015, pp. 88–94. Pubmed, doi:10.1016/j.jss.2014.08.062.
Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C, Mehrotra S. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res. 2015 Jan;193(1):88–94.
Journal cover image

Published In

J Surg Res

DOI

EISSN

1095-8673

Publication Date

January 2015

Volume

193

Issue

1

Start / End Page

88 / 94

Location

United States

Related Subject Headings

  • Surgery
  • Specialties, Surgical
  • Risk Assessment
  • Reproducibility of Results
  • Probability
  • Preoperative Care
  • Outcome and Process Assessment, Health Care
  • Medical Errors
  • Intraoperative Care
  • Humans