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Wrong-Site Surgeries and Falls Significantly Decreased As Result Of Prevention Program

Wrong-site surgery and harmful fall prevention tactics appear to be working. According to the June Pennsylvania Patient Safety Advisory, there has been a decline in the number of reports filed. Wrong-site procedures occur when surgeons operate on a body part other than that intended.

Since the Patient Safety Authority started prevention programs in 2007, the rate of wrong-site surgeries decreased 40%, from 2.4 per 100,000 patients from 2007-2008 to 1.4 per 100,000 from 2010-2011. This year, reports have decreased from an average of 19 per quarter to 12 per quarter.

John Clarke, Physician Director for the Pennsylvania Patient Safety Authority, said the number of complaints received was alarming. "We were getting reports of wrong-site surgery on a regular basis, an average of one per week, and this seemed intractable to me and also unexplainable," Clarke said.

In April, the Authority started another wrong-site surgery initiative funded by the Centers for Medicare and Medicaid Services (CMS). It includes 26 Pennsylvania healthcare facilities. Clarke said he feels confident they are all committed to further reducing the number of surgical errors.

"They have people inside the institution who begin to own the problem and own the solution, particularly when they share their information across institutions and relay their success stories and their failures and trying to implement these best practices. We find that we get the most success that way," Clarke said.

Patient Falls On The Decline

In 2008, the Authority began a harmful falls in medical facilities prevention program. After the first two years, the project reported five consecutive quarters of steady decline. During that period, there were 14,571 patient falls reported and 97.4% of those did not result in injury. The program involving more than 80 healthcare facilities is also funded by CMS.

Clarke said although the prevention practices are not mandated, they are strongly encouraged by the Authority. "Our premise is we will tell you the best way of doing things and we will tell you that when people do things this way, they get good results. Hopefully they'll be motivated to implement these programs," Clarke said.