Steps to Prevent Wrong-Site Surgery

Internal Medicine World Report, March 2014,

According to the American Academy of Orthopaedic Surgeons, 84% of wrong-site orthopedic surgery claims result in indemnity payments over a 10-year period, representing financially burdensome settlements.

When most physicians think of wrong-site surgery, they envision a surgeon removing the wrong limb. Fortunately, wrong-site surgery occurs only rarely, though it still reflects on poor systemic planning and a host of other failures.

According to the American Academy of Orthopaedic Surgeons (AAOS), the number of wrong-site cases is low compared to other professional liability insurance claims; nevertheless, 84% of wrong-site orthopedic surgery claims result in indemnity payments over a 10-year period, representing financially burdensome settlements.

The January-March 2014 issue of Urology Annals included a study examining the causes and remedies of wrong-site surgery. The authors specifically looked at urologic surgeries that include kidney, ureter, or testis surgical sites. They noted that a broken or deformed limb is often visually obvious, whereas surgery on organs must be guided by the medical record and its imaging content.

The researchers conducted a retrospective review of 150 patient charts, with kidney, ureter, and the testis each accounting for 50 cases. Within those charts, they examined clinical records, consent forms, and radiology reports.

According to their results, the wrong site was most often marked as a result of a surgical team member misinterpreting clinical records or radiology reports.

Almost 9% of clinic records failed to identify the side on which the disease was present. Five records identified the wrong side of the body, while 3 made no mention of the side. All consent forms included the correct side, and in all cases, the incorrect surgical mark was identified, corrected, and no wrong side surgery was performed.

The researchers recommended clearly indicating the correct side in every medical record, theatre list, and consent form when a procedure involves a bilateral organ, in order to prevent confusion. Although it seems simple, it’s a step that is often overlooked. Thus, all surgeons should train their office staff and surgical teams to make note of the correct side, and remind others to do so when they forget.