The Facts About Wrong Site Surgery
Wrong site surgeries are a relatively rare medical mistake, but when they happen, the results can be devastating and can cause long-term problems for the patient. As unfortunate and unacceptable as wrong site surgeries are, the most unfortunate thing about them is they are usually completely preventable and are very commonly the result of a lack of communication.
What Is A Wrong Site Surgery?
Wrong site surgeries are procedures that are mistakenly performed on a spot where it is not needed instead of the intended area. The term “wrong site surgery” not only covers procedures performed on the wrong location, but also surgeries performed on the wrong person and cases where the wrong procedure is performed all together.
How Common Are Wrong Site Surgeries?
Wrong site surgeries are relatively rare, less common than other types of medical mistakes, but they’re also believed to be more common than published statistics suggest. It can be difficult to determine exactly how common wrong site surgeries are because it is not always mandatory to report incidences of wrong site surgeries. In 2011, the Joint Commission Center For Transforming Healthcare announced they believe 40 instances of wrong site surgery happen every week in the United States. A 2006 study by The Agency for Healthcare Research and Quality analyzed data from approximately 3 million surgeries performed between 1985 and 2004 and found that wrong site surgeries happened in 1 out of 112,994 surgical procedures. However, this data only included surgeries performed in operating rooms and it is believed the majority of wrong site surgeries happen in procedures performed outside of operating rooms.
Preventing Wrong Site Surgeries
Since July 2004, all accredited hospitals, office-based surgical facilities, and ambulatory care services in the United States have been required to follow the Universal Protocol. The Universal Protocol was designed to reduce wrong site surgeries by standardizing the preoperative procedure and clarifying communications. The Universal Protocol includes verifying the identity of the patient, confirming the procedure to be performed and where it is to be performed, marking the site of the surgery, having the patient verify their identity and where the procedure is supposed to occur, and taking a brief time-out before the start of the surgery so the members of the surgical team can once again verify the identity of the patient, the procedure being performed, and where it is to be performed.
However, the Universal Protocol is not failproof and wrong site surgeries do still happen despite these measures. It’s estimated that one third of wrong site surgeries are the result of mistakes that were made long before the day of the surgery, such as a report being labeled inaccurately. Sometimes steps of the Universal Protocol might be rushed or not properly completed in emergency situations. Studies have found the time-out portion of the Universal Protocol can be extremely effective in preventing wrong site surgeries, but this step is sometimes rushed in emergency situations or when a large number of procedures are scheduled on a particular day.