Wrong-site surgery, related injuries appear to be rare

April 17, 2006

A review of cases reported to one large malpractice insurer over 20 years indicates that wrong-site surgery and related serious injuries are rare and that current national protocols for verifying the surgical site, if applied, may have prevented only two-thirds of cases, according to a study in the April issue of Archives of Surgery, one of the JAMA/Archives journals.

Wrong-site surgery includes procedures that are performed on the incorrect person, organ or limb, or spinal procedures performed at the wrong level, according to background information in the article. Such cases have attracted national attention and mobilized prevention efforts. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed a protocol that all accredited hospitals must now implement. The three minimum requirements are preoperative verification of site and patient, marking the surgical site on the patient, and the institution of a "time out" in the operating room, the authors write.

Mary R. Kwaan, M.D., M.P.H., Brigham and Women's Hospital and Harvard School of Public Health, Boston, and colleagues examined wrong-site surgery cases reported to one large malpractice insurer between 1985 and 2004. The insurer provides liability coverage to one-third of Massachusetts's physicians and approximately 30 hospitals, which performed a total of 2,826,367 operations during the study period. The researchers searched the insurer's database for malpractice claims and loss observations, which are reports from hospitals to the insurer, related to surgery. They then reviewed text abstracts of the cases they found to identify those that involved wrong-site errors. In addition, information about protocols to prevent wrong-site surgery was collected in 2004 from 28 hospitals covered by four malpractice insurers in New England and Texas.

In their review of insurance records, the authors identified 40 cases of wrong-site surgery, 25 of which did not involve the spine--a rate of one in 112,994 nonspine procedures, the authors write. Review of medical records for 13 of the cases suggested that implementation of the JCAHO protocol would have prevented eight (62 percent) of them. Of those 13 cases, one patient was permanently and significantly injured, two had major but temporary injuries and ten had injuries that were temporary and minor or insignificant.

In reviewing the hospital protocols, the researchers found that they had an average of 12 redundant checks on the correct surgical site involving two to four hospital staff members. "No published evidence offers guidance on the effectiveness of site-verification interventions," the authors write. "Simplification of protocols would improve adherence and efficiency and allow surgical teams to focus their limited time and energy on prevention of more common or harmful errors."

"Wrong-site surgery is rare but shocking to the public," they conclude. "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."
(Arch Surg. 2006;141:353-358. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This study was supported by a grant from the Agency for Healthcare Research and Quality, Rockville, Md. Dr. Kwaan was funded by a postdoctoral fellowship from the Agency for Healthcare Research and Quality.

The JAMA Network Journals

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