10 things to know about wrong-site surgery

Wrong-site surgery is defined as "never events," that unfortunately are not all that uncommon.

Here are 10 things to know about wrong-site surgery:

1. Of the events reviewed by the Joint Commission between 1995 to 2000, wrong-site surgery incidence accounted for 13.4 percent of cases. The Joint Commission on Accreditation of Healthcare Organizations of the USA defined these events as "unexpected events in a healthcare setting that cause serious physical or psychology injury, or risk to a patient that is not related to the natural course of the patient's illness."

2.The Joint Commission Sentinel Event program identifies wrong-site surgery as a rather common instance of a sentinel event. The Joint Commission has published two Sentinel Event Alert newsletters addressing wrong-site surgery. The first was published in 1998, followed by a second in 2001. In 2004, the Joint Commission held its first World Wrong Site Surgery Summit and launched the Universal protocol.

3. In the United States, 9,744 malpractice settlements for surgical "never events" were paid from 1990 to 2010 totaling $1.3 billion. Of these settlements, approximately 6 percent of patients died, 32.9 percent of patients suffered a permanent injury and 59.2 percent of patients experienced temporary injuries.

4. The Joint Commission projects as many as 50 wrong-site incidents occur each week in the United States.

5. The Joint Commission launched an initiative titled "The Joint Commission Center for Transforming Healthcare Project" in an effort to combat the number of wrong-site procedures that occur on a weekly basis. In the project, eight U.S. hospitals and ambulatory surgery centers measured the risk of wrong-site surgery in each of their perioperative processes. They found specific factors causing risks and devised solutions to solve them. The organization reduced the number of surgical cases for wrong-site procedures by 46 percent in the scheduling area, 63 percent in the pre-op/holding area and 51 percent in the operating room.

6. An AHRQ study found that wrong-site errors occur in approximately 1 out of 112,000 surgical procedures, indicating that an individual hospital would only experience one wrong-site error every five to 10 years. Authors of the study claimed the Joint Commission's Universal Protocol may have prevented 62 percent of the cases reviewed.

7. A study surveying orthopedic surgeons found that of the 9,255 orthopedic surgeons who submitted 1.3 million cases cases, 61 of these surgeons reported performing 76 wrong-site surgical procedures from 1999 through 2010, according to the Journal of Bone & Joint Surgery. In the study, spine surgeons were the most likely to report wrong-site surgery, with single-level lumbar laminotomy being the most common wrong-site procedure.

8.  Wrong level surgery is not a rare occurrence among spine surgeons. A study by the Agency for Healthcare Research and Quality surveyed more than 400 surgeons. The study found 50 percent of respondents had performed a wrong level surgery at least once during their career.

9. Rhode Island Hospital, a prestigious medical center and teaching hospital for Brown University, faced scrutiny when three wrong-site surgeries occurred at the hospital in less than a year in 2007. In one incident, a neurosurgeon operated on the wrong side of the brain when inserting a drain into a patient's head.

In another case, a physician in training cut the wrong side of a patient's head after skipping a pre-operation checklist. The surgeon cut into the wrong side of the head after he failed to mark the correct side on a consent form.

A chief resident began brain surgery in the wrong place in the hospital's third incident of wrong-site surgery that occurred in November 2007. Although a nurse witnessed the surgeon making the mistake, she failed to speak up.

10. There is not one factor that leads to wrong site surgery, but usually is a compilation of small errors. Errors that contribute to wrong site surgery include booking errors, verification errors, distractions, inconsistent site marking, lack of a safety culture and time out errors. Surgical facilities must be aware of all these factors that could lead to wrong site surgery and take the necessary preventative measures. Click here for solutions to amend these errors.

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