• Article
  • June 19, 2019

New Safety Alert Shows Children at Risk During Invasive Procedures

Difficult-to-mark surgical sites pose a significant risk to pediatric patients, lead to additional treatments, longer hospital stays and higher medical costs.

Wrong-site surgeries occur approximately 40 times per week across all U.S. hospitals. While improvement efforts to address these errors have successfully reduced patient harm, children's hospitals continue reporting wrong-site surgeries to the Child Health Patient Safety Organization (PSO). In fact, 2% of cases the PSO analyzed from hospital reporting are categorized as wrong-site surgeries. These errors aren’t limited to the operating rooms; they occur anywhere invasive procedures are performed, which could make it even more challenging to ensure standards are followed. 

Recent data compiled by the PSO show difficult-to-mark surgical sites pose a significant risk. They are discussed less frequently than other more well-known causes of wrong-site procedures such as surgery on the wrong side, but these errors can also lead to additional treatments, longer hospital stays and higher medical costs.

Hospitals may not know they have the potential for this serious safety event unless they look for it, or it happens in their organization. The PSO’s patient safety alert can help teams proactively assess their environment for the risks and implement site marking practices that prevent these events.

5 actions to prevent errors during invasive procedures

The safety alert includes causes, considerations and actions members can take, including:

  1. Identify settings where procedures occur, and which require an alternative site marking process.
  2. Identify procedures involving sites that are anatomically impossible or impractical to mark.
  3. Conduct an assessment to compare actual practice with written policies.
  4. Establish simulated training activities for alternative site marking procedures.
  5. Develop job aides and real-time reminders for providers when sites are impossible to mark, or patient/family refuses marking.

The PSO issues safety alerts after detecting harm that could be repeated in pediatric health care. Find the wrong-site safety alert and a library of other safety alerts.

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