Wrong-site Surgery

Wrong-site surgery is still occurring despite wide adoption of prevention strategies.

In attention-getting headlines, the media is reporting that wrong-site surgery occurs about 40 times a week in the USA. I thought this seemed high, especially considering that wrong-site surgery is considered a “never event” and prevention strategies, such as a “time out“ prior to surgery and patient participation in marking the surgical site, are now routine. Much to my surprise, this statistic is correct.

The Joint Commission Center for Transforming Healthcare is conducting a surgical safety project with 8 hospitals and ambulatory surgery centers and released its preliminary findings in September 2011. The project tracked the incidence of wrong-site surgery, which includes invasive procedures on the wrong patient in addition to wrong-procedure, wrong-site, and wrong-side surgeries. With about 40 wrong-site surgical procedures occurring each week in the USA, the obvious question is how does this happen?

The Joint Commission Center found that misinformation about a patient and scheduling errors were factors that contributed to wrong-site surgical errors; as was ineffective communication and distractions in the operating room. Another contributing factor was a "time out" that was conducted without full participation by all key people in the operating room. As the researchers noted, wrong-site surgical procedures are rare events that occur from multiple errors or a cascade of errors.

Strategies to decrease the occurrence of wrong-site surgical procedures include standardization of safety procedures. For example, hospitals and ambulatory surgery centers should have a consistent approach to patient identification verification and site marking (e.g. always done in the holding area). Similarly, “time outs” need to be standardized and have a designated “lead person” who consistently conducts them. Hopefully, operating room personnel will take notice of the Joint Commission Center’s preliminary findings and strive to prevent wrong-site surgery from occurring.

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