Wrong-site surgery encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body, as well as the wrong procedure at the correct anatomical site1. Wrong-site surgeries occur across all surgical specialties, with the highest prevalence affecting orthopedic and dental surgical specialties 4. Despite efforts to curb them, such errors continue to occur at significant rates. This error represented the third most common sentinel event in 2016, 2017, and 2018, as individual case reports continue to be documented on a regular basis around the world 2. Furthermore, wrong-site surgery is likely to be underreported due to fear of litigation 3.
Wrong-site surgeries may be devastating to the patient, nurses, surgical staff, and facility in which the surgery was carried out. Indeed, in addition to patients, consequences may dramatically affect clinicians as well. A wrong-site surgery has led to many malpractice claims and may result in state licensure boards imposing penalties on surgeons and some insurers no longer paying providers.
This major error can be attributed to a number of common causes, alongside systemic failures. While some instances are solely linked to error on the part of the surgeon, most wrong-site events result from multiple organizational process failures implicating a multidisciplinary operating team.
The prevention of wrong-site surgeries warrants thorough case documentation, the deployment of innovative technologies, and the implementation of successful safety initiatives – all the while reducing the shame surrounding such events 4.
As part of the National Patient Safety Goals chapter of the Joint Commission accreditation manual, the Joint Commission established its Universal Protocol to address the problem in 2004 5. The Universal Protocol stipulates that clinical staff must mark the surgical site, confirm patient identity, confirm the intended procedure, and review these details among the surgical team immediately prior to the surgical intervention. While specific in content, these guidelines vary widely in the way in which they are implemented and adhered to across medical settings and clinical staff.
Involving the patient in marking the side of surgery minimizes the incidence of wrong-site operations – despite ineffective communication channels. Patients should remain actively engaged in every aspect of their care, confirming their identity and feeling empowered to alert and question clinicians as necessary.
Meanwhile, it is equally important that clinicians remain educated and aware. A barrier to reducing the incidence of wrong-site surgery is when clinicians believe that they would not perform such an error given its rarity – however, a humble, engaged attitude is paramount to eliminating all errors.
Since misinterpretation is a major cause of wrong-site surgery, it is important that the surgical site and side be explicitly mentioned in every consent form, clinic letter, and on the operating theater list. Next, as recommended by an American Academy of Orthopaedic Surgeons (AAOS) task force, the surgeon should inscribe their initials at the precise surgical site and side 6.
Standardizing and streamlining workflows is equally crucial to minimizing the incidence of preventable errors. In so doing, a surgical safety list is essential to preventing an array of clinical errors. The World Health Organization (WHO) surgical safety checklist has already been effective at minimizing the incidence of wrong-site surgery within the UK’s National Health Service, for example 7. However, to be efficient, such site verification protocols need to be as simple and streamlined as possible 8.
Finally, innovative technologies capitalizing on most of these aforementioned factors may also be used to minimize the incidence of wrong-site surgery. To this end, a systems-based approach was used to recently develop one such tool, the StartBox system, which consisted of an application used to acquire procedural data, assess near-misses, and evaluate the occurrence of wrong-site surgeries. The tool also creates an audio recording detailing the surgical protocol to be listened to and amended at any time, and does not let the surgeon begin their operation until the patient’s identity and surgical procedure, site, and side have been preoperatively confirmed and documented by the surgical team. So far, using this system has resulted in the total absence of any wrong-site surgical occurrences 9.
Clearly, a multipronged approach integrating safety checklists, workflow standardization and streamlining, and data-driven technologies will be key to lowering the rates of wrong-site surgeries into the future.
References
1. Wrong-Site Surgery. Available at: https://www.ecri.org/search-results/member-preview/hrc/pages/surgan26.
2. Nwosu, A. The horror of wrong-site surgery continues: Report of two cases in a regional trauma centre in Nigeria. Patient Saf. Surg. (2015). doi:10.1186/s13037-014-0053-2
3. Mulloy, D. F. & Hughes, R. G. Wrong-Site Surgery: A Preventable Medical Error. Patient Saf. Qual. An Evidence-Based Handb. Nurses (2008).
4. Seiden, S. C. & Barach, P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable? Arch. Surg. (2006). doi:10.1001/archsurg.141.9.931
5. Universal Protocol | The Joint Commission. Available at: https://www.jointcommission.org/en/standards/universal-protocol/.
6. Cowell, H. R. Editorial – Wrong-Site Surgery. J. Bone Jt. Surg. (1998). doi:10.2106/00004623-199804000-00001
7. Hanchanale, V., Rao, A. R., Motiwala, H. & Karim, O. M. A. Wrong site surgery! How can we stop it? Urol. Ann. (2014). doi:10.4103/0974-7796.127031
8. Kwaan, M. R. et al. Incidence, patterns, and prevention of wrong-site surgery. Archives of Surgery (2006). doi:10.1001/archsurg.141.4.353
9. Gloystein, D. M., Heiges, B. A., Schwartz, D. G., DeVine, J. G. & Spratt, D. Innovative Technology System to Prevent Wrong Site Surgery and Capture Near Misses: A Multi-Center Review of 487 Cases. Front. Surg. (2020). doi:10.3389/fsurg.2020.563337
