Wrong-Site, Wrong-Procedure, and Wrong Patient Adverse Events: Are They Preventable?

The Journal of Emergency Medicine safe and feasible and may decrease mortality due to faster reperfusion with PCI, a strategy associated with more complete and sustained reperfusion than thrombolytics. [E. Willis Nottingham III, MD, Denver Health Medical Center, Denver, CO] Comment: Limitations to this study include the fact that 80% of the control group patients received thrombolytic therapy rather than PCI (and they received it in a mean door-toneedle time of 41 minutes) so it is unclear how much of the mortality benefit is from type of reperfusion strategy vs. the protocol triage mechanism. The control patients were also selected from a database from only two of the four participating hospitals, so there is possible selection bias if these patients differ in ways the study did not measure. There was also no mention of any accounting of difference in patient management (in-hospital or pre-hospital) that may have occurred between the control period (2001–2003) and the protocol period (2004 – 2005). This study might not be applicable for metropolitan areas where PCI centers are farther than this study’s 12 km from alternative emergency departments.

e WRONG-SIDE/WRONG-SITE, WRONG-PROCEDURE, AND WRONG PATIENT ADVERSE EVENTS: ARE THEY PREVENTABLE? Seiden SC, Barach P. Arch Surg 2006;141:931–9. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) are a frequent topic of discussion for their roles in unnecessary deaths, disability, suffering, malpractice, and erosion of public confidence in the health care system. This study analyzed reports of WSPEs from four databases: the National Practitioner Data Bank (NPDB); the Florida Code 15 mandatory reporting system; the American Society of Anesthesiologists (ASA) Closed Claims Project Database; and the authors’ anonymous, web-based incident-reporting tool. Data from these four sources, review of current literature, and discussion with regulators show that WSPEs are much more common than previously reported. The authors estimate that 1300 to 2700 WSPEs occur in the United States annually. These databases underreport because in most cases, they track only those WSPEs that resulted in a claim or are based on self-reporting with a potential for punitive action. They recommend that reporting WSPEs and near-misses in a non-punitive, constructive environment should be incorporated into the curriculum of all health care professionals. They also maintain that all health care professionals involved in a procedure, as well as the patient, must be actively involved in ensuring that the correct procedure is done. This is best accomplished with a team training approach. They also recommend that human factor analyses be performed after all WSPEs, as well as continued development of patient-identification systems. [Molly E.W. Thiessen, MD, Denver Health Medical Center, Denver, CO] Comment: The current reporting systems for WSPEs have the potential to underestimate the actual occurrence of these events, and it is difficult to estimate their true incidence and

327 subsequent effects. It is therefore important for each physician to work with both the patients and the health care team to avoid these errors.

e PREHOSPITAL HYPOXIA AFFECTS OUTCOME IN PATIENTS WITH TRAUMATIC BRAIN INJURY: A PROSPECTIVE MULTICENTER STUDY. Chi JH, Knudson MM, Vassar MJ, et al. J Trauma 2006;61:1134 – 41. This prospective, multicenter cohort study identified patients with suspected head injury who underwent helicopter transport to a level I trauma center and examined the association of secondary insults (hypoxia – SpO2 ⬍ 92% and hypotension; systolic blood pressure ⬍ 90 mm Hg) with mortality and disability at discharge. Of 319 patients transferred to level I trauma centers in four different cities (Dayton, OH; Philadelphia, PA; Davis and Fresno, CA) with suspected brain injury over a 2-year period, 150 had acute traumatic brain injury identified by computed tomography (CT) scan, operative findings or autopsy, or had a head Abbreviated Injury Scale (AIS) score of at least 3 or a Glasgow Coma Scale (GCS) score of ⬍12 within the first 24 hours of admission, and were included in this study. Bivariate analyses were performed to determine the association of the presence, duration, and frequency of hypotension and hypoxia with dependent variables. This information was used to identify covariates for multivariate logistic regression analysis. Bivariate analyses found that hypoxia, older age, lower GCS score, Marshall score, head AIS score, and multiple trauma had a significant effect on mortality, whereas hypotension, Injury Severity Scale (ISS) score, need for intracranial or extracranial surgery and lung injury were not significant predictors of mortality. In multivariate analyses, hypoxia, age ⬎ 65 years, and GCS score of ⱕ 8 were independent predictors of mortality, whereas hypotension was not. Secondary insults were associated with an increased Disability Rating Scale (DRS) of ⬎15 and increased length of hospital stay. The authors conclude that prehospital insults, particularly hypoxia, have a significant effect on mortality and disability in patients with traumatic brain injury. They stress the importance of further studies to examine the relationship between traumatic brain injury and pulmonary dysfunction. [Molly E.W. Thiessen, MD, Denver Health Medical Center, Denver, CO] Comment: Although this study does establish the relationship between prehospital hypoxia and mortality and disability, the authors stress that there was no difference in outcome between patients with respect to intubation status. It is for this reason that more research regarding pulmonary dysfunction related to brain injury is paramount, as noted above.

e APPLICATION OF ULTRASONOGRAPHY FOR BLUNT LARYNGO-CERVICAL-TRACHEAL INJURY. Moriwaki Y, Sugiyama M, Fujita S, et al. J Trauma 2006;61: 1156 – 61. This study from Japan utilized ultrasound (US) for the preliminary evaluation of blunt laryngo-cervical-tracheal injury