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Wrong-Site Surgery: What Is It and Why Does It Happen?
Wrong-site surgery is a horrible type of medical negligence. The Joint Commission on Accreditation of Hospitals, an independent, not-for-profit organization, has developed the Universal Protocol to help prevent such surgical errors.

Wrong–site surgery is a one of the most preventable forms of medical malpractice because it is so unnecessary. It indicates sloppiness in procedure and a level of inattention to detail you would hope to never find in a surgeon or their staff.

While there are often explanations, there is never any excuse. It might be excusable in an emergency military hospital, with surgeons operating under a crush of battle injured patients, but it should simply never occur in a modern hospital.

A statement from the website of the American Academy of Orthopaedic Surgeons notes: “Wrong-site surgery is not just an orthopaedic surgery problem that occurs because the surgeon operates on the wrong limb. This is a system problem that affects other surgical specialties as well.”

It, of course, also affects patient care and surgical outcomes.

How Often Does Wrong-Site Surgery Happen?

A report entitled “Avoiding Wrong Site Surgery” from the journal SPINE, found that determining the statistical rate of wrong-site surgery was difficult because of the variables of the studies surveyed. It states dryly, “Study methods and definitions of wrong site surgery were so different that a pooled rate calculation was not possible.”

Nonetheless, the article cites a report done by the Joint Commission that gives some idea as to the scope of the problem.

From 1995 to 2005, the Joint Commission sentinel event statistics database ranked wrong-site surgery as the second most frequently reported event with 455 of 3548 sentinel events or 12.8 percent. The Joint Commission on Accreditation of Hospitals is an independent, not-for-profit organization the primary purpose of which is to provide voluntary accreditation for hospitals.

Twelve percent might not seem like a major problem confronting doctors, but when you consider that every case of wrong-site surgery is one of negligence, plus the likelihood of underreporting since much of the data is self-reported by doctors, the problem is far larger than it should be.

Definition of Wrong-Site Surgery

The Joint Commission defines wrong-site surgery as any surgery performed on the wrong site or patient, or performance of the wrong procedure.

  • Wrong-site surgery is a broad term that encompasses any surgical procedure performed on the wrong body part or wrong patient.
  • Wrong-level or wrong-part surgery is a surgical procedure performed at the correct site, but at the wrong level or part of the operative field.
  • Wrong-patient surgery is a misidentification of the correct patient, causing a procedure to be performed on the wrong patient.

A common form of wrong-site surgery is wrong-side surgery, when a surgical procedure is performed on the wrong extremity or wrong side of the body. This happens most often with body parts that are duplicated such as arm, hands, legs, feet, eyes, lungs and kidneys.

Universal Protocol

The Universal Protocol was created to help reduce the occurrence of wrong-site, wrong-procedure and wrong-person surgery in Joint Commission-accredited organizations.

The protocol requires a surgical team to verify all significant elements of the surgical procedure before it begins. In addition to the preoperative verification, a “time out” should be conducted in the operating room before surgery.

The time out should include the entire operative team and the use of active communication, and should be documented such as in a checklist that should note the:

  • Correct patient identity
  • Correct side and site
  • Agreement on the procedure to be done
  • Correct patient position
  • Availability of implants and/or special equipment

The time out is designed to force everyone involved with the surgery to take the time to be absolutely certain he or she has identified the correct patient, site and side, and has the equipment necessary to perform the procedure.

The Joint Commission approved the Universal Protocol in July 2003 and it became effective in July 2004 for all accredited facilities.

It’s in the Details

Some have recommended that the surgeon meet the patient before the procedure while the patient is conscious, and then write his or her initials clearly on the patient’s operative site to clarify the proper surgical area.

Checklists can help ensure accuracy and correct patient identification, reducing surgical errors.

This is not, as they say, brain surgery, even if it is done for brain surgery.

It requires discipline and attention to detail, as safety procedures must be followed every time in the same manner. Like the checklists for airline pilots, the surgical checklist needs to be employed with military discipline because it may be a matter of life or death.

If You Are a Victim of Wrong-Site Surgery

Wrong-site surgery is medical malpractice. If you wake up after the anesthetic wears off and find something very, very wrong, speak with an attorney experienced with medical malpractice cases. A lawyer can fight for just compensation for the error.

Keywords: wrong-site surgery, medical malpractice, negligence, Universal Protocol, surgical error, checklist
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