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Study Finds Wrong-Site Surgery Is Rare

Simple, efficient site-verification protocols necessary but surgeon is ultimately responsible

TUESDAY, April 18 (HealthDay News) -- An analysis of over 2.8 million surgeries at institutions in the United States finds that while wrong-site surgery is unacceptable, it is "exceedingly rare" and major injury from it is even rarer. The results are published in the April issue of the Archives of Surgery.

Mary R. Kwaan, M.D., M.P.H., from Brigham and Women's Hospital in Boston, and colleagues examined all wrong-site surgery cases reported by a large malpractice insurer between 1985 and 2004 to determine the incidence, characteristics and causes of wrong-site surgery. The group also examined site-verification protocols.

The investigators found 40 cases of wrong-site surgery, 25 of which were non-spine, producing an incidence of 1 in 112,994 operations. If all hospitals had used the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol, including preoperative site and patient verification, marking the site and an operating room time out, it would have prevented two-thirds of these incidents. Of these cases, one patient was permanently and significantly injured, two had major but non-permanent injuries, and the remainder were minor and temporary.

"Wrong-site surgery is rare but shocking to the public," the authors write. "This mandates an approach that balances safety, simplicity and efficiency. No protocol will prevent all cases. Therefore, it will ultimately remain the surgeon's responsibility to ensure the correct site of operation in every case."

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