Association also sent related resource to members

The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) recently reviewed data from the adverse health event reporting system that revealed that two types of wrong-site adverse health events have been occurring.

One type has involved anesthesia procedures, such as regional nerve blocks and injections, performed prior to a surgical procedure. Root-cause analyses indicated that in most of the cases, the anesthesia procedures and the surgical procedures were not treated as two separate, invasive procedures with two separate site markings and time-outs. In many cases, the surgical procedure site had been marked and a time-out was completed, but the same had not happened for the anesthesia procedure.

As a result of the findings, MHA and MDH issued the following Minnesota Patient Safety Alert to hospitals last week: PDF. The alert recommends, for example, that hospitals clarify in their surgical policies and processes that separate site markings and safety time-outs are necessary for such anesthesia procedures.

The second type of wrong-site events that have been reported recently involved site markings that had not been visually identified just prior to the procedure start. Analysis indicated that, in most such adverse event cases, the site mark was out of view because the patient's body had been prepped and draped. The surgical team had begun the procedure without first looking for and locating the site mark.

View the related Minnesota Patient Safety Alert, which was also sent to hospitals, here: PDF.

MHA also sent to members this handout about checking for site markings - hospitals may share it with their surgical and procedural teams as they wish: PDF.

View other advisories issued since 2005 here. For more information, contact Julie Apold, MHA director of patient safety, at (651) 603-3538 or Tania Daniels, MHA vice president of patient safety, at (651) 603-3517.