Wrong Site Surgery Is Rare

April 17, 2006 -- For surgery patients, the odds of getting wrong-site surgery are small -- about one in 113,000 -- a new study shows.

But the study doesn't dismiss wrong-site surgery, in which doctors mistakenly operate on the wrong patient or body location.

"Wrong-site surgery is rare but shocking to the public," write Mary Kwaan, MD, MPH, and colleagues in the Archives of Surgery.

"No protocol will prevent all cases," Kwaan's team continues. "Therefore, it will ultimately remain the surgeon's responsibility to ensure the correct site of operation in every case."

Kwaan works at Harvard School of Public Health and in the surgery department of Boston's Brigham and Women's Hospital.

Rare Cases

Kwaan's data come from malpractice claims filed with a large malpractice insurer from 1985 to 2004. The insurance company covered about a third of doctors in Massachusetts and roughly 30 hospitals.

The researchers found 40 claims that involved wrong-site surgery out of nearly 3 million operations covered during the study period. Of those claims, 25 operations didn't involve the spine.

"Therefore, the estimated incidence rate for nonspine wrong-site surgery was one in 112,994 operations," Kwaan and colleagues write.

Medical records were available for 13 of the cases. Of those 13 cases, 10 were "temporary" and "minor" or "insignificant," while one was "permanent and significant," the researchers write.

Protecting Against Errors

The study was funded by the Agency for Healthcare Research and Quality (AHRQ), a branch of the U.S. Department of Health and Human Services.

"The good news is that wrong-site surgery is extremely rare, and major injury from it even less common," says AHRQ Director Carolyn Clancy, MD, in a news release.

"The less-good news is that although site-verification protocols offer some protection against such errors, they are not foolproof," Clancy continues. "We have a lot more to do to ensure that wrong-site surgery never happens."

In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a protocol to help prevent wrong-site surgeries. That protocol probably wouldn't have prevented five of the 13 cases for which medical records were available, write Kwaan and colleagues.

Preventive Steps

It probably isn't possible to completely prevent wrong-site surgeries, Kwaan and colleagues note. They write that "up to 20 checks per patient" are required to help prevent wrong-site surgeries and that simplifying those checks is a good idea.

The researchers recommend these four steps to reduce wrong-site surgeries:

• Mark the site intended for surgery.
• Verify the patient's identity and procedure before surgery.
• Check with the patient and at least one of the inspecting caregivers about any inconsistencies before surgery.
• Get informed consent from the patient about the surgery site.

Curious about the cases Kwaan's team found? In one case, a hospital printed a magnetic resonance image (MRI) of a knee of the wrong patient, who had the same name as the patient who was getting surgery.

In another case, the patient's correct foot was marked for toe surgery, but the correct toe wasn't marked. Two other patients had multiple lesions and uncertainty about which lesion should be removed. Errors on the operating-room schedule were involved in two other cases, the study shows.

SOURCES: Kwaan, M. Archives of Surgery, April 2006; vol 141: pp 353-358. News release, Agency for Healthcare Research and Quality. News release, JAMA/Archives.