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Wrong site surgery – the five year national experience

Posted Jun 04 2010 12:00am

  From the August 2009 Newsletter of the Premier Safety Institute

  With 2,700 cases of wrong-site surgery continuing to occur annually, experts recommend more consistent adoption of the Universal Protocol (UP), or in this case, a defined alternative process when site-marking is impractical.

  A recent review of the National Practitioner Data Bank and additional closed claims databases for wrong-site procedures estimated that wrong-site surgery continues to occur approximately 1,300 to 2,700 times annually in the United States, despite the Joint Commission (TJC) requirement for a UP five years ago. In addition, up to 30 percent of all wrong-site and wrong-patient procedures have their genesis before patient admission to the hospital from scenarios such as inaccurate clinic note dictations or mislabeling of radiographs, reinforcing the need for the UP to prevent error.

  The UP was introduced by TJC in July 2004 as a National Patient Safety Goal and consists of three components: a pre-procedure verification process, surgical site marking, and a surgical "timeout" immediately prior to starting the procedure.

  Expansion of "timeout"
The timeout was recently expanded to include the verification of correct patient positioning, availability of relevant documents, diagnostic images, instruments and implants, and the need for preoperative antibiotics and other essential medications, e.g., the use of beta-blockers. Some disagree with an expanded approach, believing that it dilutes the original intent. However, many hospitals have found it to be helpful to improve all the processes of care.

  Less widely publicized are wrong-site invasive procedures performed outside the operating room, highlighting the reason that this protocol should be applied equally to clinical settings outside the operating room for any invasive procedure that requires a patient's consent.

  Improper surgical site-marking a common risk factor
  Inadequate or inaccurate surgical site-marking represent a major risk factor for wrong-site surgery. Examples that have led to error include site-marking by a junior member of the surgical team who will not be present during the procedure, using an "X" that may be misunderstood as "not this side," the use of non-permanent markers that wash off during surgical prep, residual markings from previous surgery, or inability to mark the site (e.g., mucosal surfaces, teeth, visceral surgery).

  Challenges with adoption of UP
  Five years after the launch of the UP, an editorial in the July 2009 issue of Patient Safety in Surgery reviewed the obstacles that have limited the effectiveness of UP and need to be addressed to improve the process. These include:

  • No consistent method for documenting correct procedure, patient, during pre-admission work-up.
  • Lack of adoption of UP across all specialties, not just surgical specialties.
  • Huge variation in site-marking methods.
  • Lack of agreement to aborting process and starting over if any objections or inconsistencies.
  • No repeated "timeout" for every additional procedure on same patient.
  • Not involving patient in the site marking.
  • Lack of an alternative site-marking process for sites unable or impractical to be marked.

(Link to original article: )

This article was reproduced with small modifications with permission from the Premier Safety Institute.  Any reference to this article should link back to their site.


DSS comment:  Reducing an event to zero is extraordinarily difficult as the medical profession is finding out.  However, institutions and practitioners are also finding out that being involved in a wrong site event creates enormous negative publicity, regulatory scrutiny, fines and even loss of practice privileges.  In addition to wrong sited surgery there exists examples of wrong sited nerve blocks, chest tube placement, and radiation therapy all of which place patients at risk.  In the case of wrong sited blocks at minimum the patient must endure the discomfort of an additional procedure.  On occasion there may be a complication from the wrongly placed block or the repeated block.  It seems to me that before any procedure some sort of time out should occur to confirm the following: 1) the correct patient is being treated, 2) the correct supplies and drugs are available, and the 3) correct site has been identified.


David S. Smith, M.D., Ph.D.

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