Cases of 'Wrong-Site Surgery' Are Rare

Such mistakes happen at rate of one in 113,000 operations, study finds

Steven Reinberg

Steven Reinberg

Updated on April 20, 2006

WEDNESDAY, April 19, 2006 (HealthDay News) -- While surgery on the wrong patient or wrong body part often makes headlines, a new study that looked at 20 years of data from a malpractice insurance provider found that cases of "wrong-site surgery" are rare.

However, the study also found that new U.S. guidelines designed to prevent wrong-site surgery would only have prevented two-thirds of the cases, the researchers found.

Wrong-site surgery includes operating on the wrong person, organ or limb, or spinal procedures performed at the wrong level. To deal with the problem, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed guidelines in 2003 that most U.S. hospitals use.

The guidelines require preoperative verification of the surgery site and patient, marking the surgical site on the patient, and a "time out" in the operating room to verify the patient data. Wrong-site errors typically result from poor communication between doctors and other hospital staff, the researchers said.

"The problem of wrong-site surgery occurs at a rate of one in 113,000 operations, which is fairly rare," said lead researcher Dr. Mary R. Kwaan, of Brigham and Women's Hospital and Harvard School of Public Health, both in Boston.

The findings appear in the April issue of the Archives of Surgery.

For the study, Kwaan's team looked at wrong-site surgery cases reported to one large malpractice insurer between 1985 and 2004.

The researchers found 40 cases of wrong-site surgery, including 25 that did not involve the spine. That's a rate of one wrong-site surgery in 112,994 non-spine procedures. In addition, a review of 13 of the cases suggested that the JCAHO guidelines would have prevented eight (62 percent) of the errors.

Of those 13 cases, one patient was permanently and significantly injured, two had major but temporary injuries, and 10 had injuries that were temporary and minor, or insignificant, the researchers said.

"Even in the best of circumstances, these protocols would not have been able to prevent five of 13 cases," Kwaan said. However, she doesn't think that spending too much time checking and rechecking before surgery would be productive.

"You can do 20 redundant checks [for the wrong site] before you have surgery, but is that really worth the amount of effort when this is probably the least common adverse effect that could happen to you?" Kwaan said.

"It would be better to spend time and energy on more common problems that are dangerous to patients," Kwaan said. These include infections, bleeding and leaving materials like sponges inside the patient, which occurs about one in 10,000 operations, she said.

Patients can help reduce the incidence of wrong-site surgery, Kwaan added. "They need to understand what operation they are having and on what part of their body," she said. "If they are confused about that, they should ask their doctor," she added.

One expert agrees that perhaps too much time is spent preventing a rare problem at the expense of other more common problems.

"I think the major lesson of the study is that we often focus improvement efforts on preventing rare yet frightening medical errors, when we could get more value from investing in less salient but ultimately greater problems in general medical quality," said Dr. William M. Sage, a professor at Columbia University Law School. "So instead of worrying so much about things like wrong-site surgery, we should pay attention to better medical management of people with diabetes, prevention of obesity, appropriate use of drugs in heart attack patients, etcetera."

"On the other hand, lots of sloppy surgical practice undoubtedly goes unreported," Sage said.

Another expert, Dr. Jeffrey Salomon, an assistant professor of surgery at Yale University School of Medicine, thinks that eliminating all risk of wrong-site surgery is impossible, but efforts should continue to make surgery as safe as possible.

"Surgery is a humbling experience for surgeons. Even when you think you have done everything correctly, something untoward can still happen," Salomon said.

He noted that the U.S. Food and Drug Administration has approved radiofrequency identification technology to help reduce wrong-site surgery using an encoded external tag that can be placed at the surgical site on the patient. The external tag is scanned with a handheld reader confirming the pertinent information for the site of the operation.

"Trying to eliminate human error is justifiable even though we know that it is unobtainable," Salomon said. "Site-verification protocols are now well accepted, unobtrusive, and give us an additional chance to avoid catastrophes. Surgery itself is inherently risky. We should never give up trying to achieve a safer surgical environment," he said.

More information

JCAHO can tell you more about wrong-site surgery.

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