Protocols Cannot Entirely Prevent Wrong-Site Surgery

A 20-year review of wrong-site surgery procedures reported to a large malpractice insurer shows that current protocols would prevent only about 60% of cases.

Researchers from the Brigham and Women's Hospital (Boston, MA, USA) and the Harvard School of Public Health (Boston, MA, USA) looked at records between 1985 and 2004 of Controlled Risk Insurance Corporation (CRICO, Cambridge, MA, USA), which provides liability insurance to a third of Massachusetts physicians and about 30 hospitals. The researchers found 25 non-spinal cases of wrong-site surgery, out of 1,426,901 inpatient and 1,399,466 outpatient surgical procedures performed during the study period. This represents an estimated incidence rate of one in 112,994 operations for non-spinal wrong-site surgery.

Of the 25 non-spinal cases, medical records were available for review in 13. Of these, only one of the cases had results regarded as both permanent and significant, while the remainder were temporary and ranged from slight scarring to a moderately or severely delayed recovery. The results were published in the April 2006 issue of Archives of Surgery.

Publicity surrounding wrong-site surgery cases has led the U.S. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to develop a protocol that all accredited hospitals must now implement. The minimum requirements of the protocol are preoperative verification of both the surgical site and the patient, marking the surgical site on the patient, and the institution of a time out in the operating room for final confirmation. The researchers stated that implementation of the JCAHO protocol would not have prevented five of the cases (38%) but "under optimal conditions” it might have prevented the other eight.

"Wrong-site surgery is rare but shocking to the public, said Dr. Mary Kwaan and colleagues. "However, at the rate detected in this study, a wrong-site surgery serious enough to result in a report to risk managers or a lawsuit would occur at a single large hospital about once every five to 10 years.”



Related Links:
Brigham and Women's Hospital
Harvard School of Public Health