Why Do So Many Wrong-Site Surgeries Occur?

It seems simple enough: take diagnostic images and an oral history. Conduct a physical exam. Read the reports of the treating doctors and nurses. There shouldn’t be any reason then for operating on the wrong part of someone’s body, removing an incorrect organ, or even operating on the wrong patient.

And yet, this particularly egregious form of medical malpractice occurs more often than we think.

What is a “wrong site surgery?”

According to the National Institute of Health, the definition of a wrong-site surgery (WSS) also includes “any invasive procedure that exposes patients to more than minimal risk, including procedures performed in settings other than the OR [operating room], such as a special procedures unit, an endoscopy unit, and an interventional radiology suite.”

Studies and strategies for addressing wrong-site surgeries

The NIH states that the reporting of wrong-site surgeries (WSS) is often underreported. Possibly only one in ten WSS are reported to the Joint Commission. These are generally considered preventable medical errors. The NIH states that because wrong-site surgeries are virtually inexcusable “state licensure boards are imposing penalties on surgeons for WSS, and some insurers have decided to no longer pay providers for WSS or wrong-person surgery, nor for leaving a foreign object in a patient’s body after surgery.”

The Joint Commission, according to the NIH, has found that the following factors contribute to wrong-site surgeries:

• Poor communication
• Noncompliance with procedures
• Lack of leadership
• Emergency cases
• Multiple surgeons
• Multiple surgical procedures
• Obese patients
• Deformities
• Time pressures
• Changes to the surgical room
• Unusual equipment

In 2003, the Joint Commission developed a set of protocols called “The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery ^TM. The protocols were developed after input from the relevant clinical specialties. The Joint Commission recommends:

• Patient identifiers and a “time-out” procedure should be used before doctors perform invasive procedures to make sure the right patient is being operated on. “To eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family.”
• As procedures are now being done in ambulatory surgical centers and doctor’s offices, which aren’t controlled by the Joint Commission, surgeons and medical teams need to aggressively monitor their surgeries to protect the patient.

The protocols should be used in hospitals, ASCs, office settings, and critical access hospitals.

The Association of Operative Registered Nurses (AORN), has developed additional wrong-site surgeries protocols and resources – through a corrective surgery toolkit. These include:

1. “an educational program on CD-ROM;
2. a pocket reference card outlining the steps necessary to promote patient identification, site marking, and the time out;
3. a template to facilitate development of a facility policy to implement the Universal Protocol for WSS;
4. a copy of the Universal Protocol for WSS and Guidelines for Implementing the Universal Protocol;
5. frequently asked questions of the Joint Commission and AORN;
6. letters to nurses, physicians, facility chief executive officers, and health care risk managers encouraging standard implementation of the Universal Protocol across all facilities;
7. information for patients about the Universal Protocol for WSS and health care safety.”

Many other medical organizations have developed their own standards for reducing the risk of wrong-site surgeries. Studies are being done to improve the Joint Commission protocols. For example, there are pros and cons to including patient input immediately before a surgery, because their input depends on their physical, mental, and cognitive states.

Doctors, nurses, surgeons, and hospitals should never operate on the wrong body part, take out the wrong organ, or operate on the wrong body part. Doctors and health providers who operate on the wrong site or commit any type of WSS should be held liable for their medical malpractice.

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