Evolution of wrong site surgery: prevention strategies

AORN Journal,  May, 2006  by Brenda L. Carney

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In 1995, a wrong leg amputation was performed on a patient at the University Community Hospital in Tampa, Fla. (1) The same patient underwent surgery two weeks later to remove the correct leg. This catastrophic surgical error resulted in the patient receiving a bilateral below-the-knee amputation instead of a unilateral below-the-knee amputation, prolonging his recovery time and greatly affecting his quality of life after surgery.

Wrong site surgeries are relatively rare and probably have occurred since people first began performing surgical procedures/ Wrong site surgery is a broad term that encompasses all surgical procedures performed on the wrong patient, wrong body part, wrong side of the body, or at the wrong level of the correctly identified anatomic site. (1) in recent years, these catastrophic surgical injuries have been brought to the attention of the public and the health care industry through the vast media avenues of television, radio, newspapers, professional publications, and the Internet. This negative media attention has resulted in some positive developments in the prevention of wrong site surgeries.

EARLY STEPS IN WRONG SITE SURGERY PREVENTION

The sentinel event described above received a great deal of publicity and, along with other much-publicized surgical mishaps, sparked the creativity of health care organizations, leading them to search for causes of and preventions for wrong site surgery in order to improve patient safety. Several groups made important early contributions to developing strategies for preventing wrong site surgery.

AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS. In 1997, the Council on Education of the American Academy of Orthopaedic Surgeons (AAOS) formed a task force to investigate data on wrong site surgery, including number of claims, mechanisms, resulting patient disabilities, and prevention methods. The task force was established as a result of national publicity about wrong site surgery and because a method for preventing wrong site surgery in orthopedic patients was needed. Findings from the task force report included data indicating that 225 orthopedic wrong site surgery claims and 106 other surgical specialty claims were filed between 1985 and 1995. (2) Insurance companies paid an average of $48,087 to patients for wrong site orthopedic surgery claims and an average of $76,167 to patients for other surgical specialty wrong site surgery claims during that time period. (2)

As a result of this and other studies, the AAOS developed an advisory statement regarding wrong site surgery. In their statement, the AAOS asserts that

   a unified effort among surgeons, hospitals
   and other health care providers
   to initiate preoperative and other institutional
   regulations can effectively
   eliminate wrong-site surgery in the
   United States. (3)

The AAOS advisory statement includes a sign-your-site checklist for safety that involves the patient confirming the surgical site as the surgeon marks the site. The checklist also involves double-checking signed consents and x-rays against the marked site, and verification of the correct site by the surgeon and other members of the surgical team. (3)

NEW YORK STATE DEPARTMENT OF HEALTH. In February 2001, the New York State Department of Health released the final report and recommendations of its preoperative protocols panel. The guidelines outlined steps for preventing wrong site surgery, wrong procedures, and procedures on wrong patients. The recommendations also emphasized the need for enhanced communication among surgical team members, three independent verifications of the surgical site, and surgeon interaction with the patient in the perioperative area. (4)

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert examining the problem of wrong site surgery in August 1998. This alert included a review of the 15 wrong site surgery cases that had been reported to JCAHO at that time. (5) As of December 2001, 150 wrong site surgery sentinel events had been reported to JCAHO, 126 of which included root cause analysis information. (6) The data indicated that 41% of wrong site surgery events were related to orthopedic/podiatric surgery; 20% to general surgery; 14% to neurosurgery; 11% to urology surgery; and the rest to specialties including dental/oral maxillofacial; cardiovascular/thoracic; ear, nose, and throat; and ophthalmologic surgery. (6) With these results, JCAHO recommended developing processes to ensure the correct surgical site, correct patient, and correct procedure. Recommendations included involving the patient in marking the surgical site, developing and using a verification checklist, and taking a "time out" in the OR to verify the correct patient, correct procedure, and correct site with active communication from each member of the surgical team. (6)

THE UNIVERSAL PROTOCOL AND SURGICAL TIME OUT