Table 24 'Wrong-Site Surgery'

PSI 23: Wrong Site-surgery
Origin: Review of an OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The consequences of wrong-site surgery can be severe. It is estimated
that one in four orthopaedic surgeons may make such an error once in
25 years of practice. Thus wrong-site surgery has potential as a patient
safety measure.
Aim of the PSI This PSI is intended to flag cases of wrong-site surgery.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Originally a JCAHO sentinel events indicator.
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21 cover
patient safety. The results suggest that this PSI may be useful as a
measure of patient safety (33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Not specified by OECD.
Numerator Description Number of procedures on the wrong patient, wrong side of the body, or
wrong organ.
Denominator Description All surgical procedures.
Data Source Not specified by OECD.
Identifying the
institutional context
In addition to being a good measure of safety, the impact of wrong-site
surgery makes this indicator important for both financial and quality
improvement policies.
Care Setting The PSI applies for high quality surgery care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
65
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring No scoring advice given.