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Related Experiment Videos

Incidence, patterns, and prevention of wrong-site surgery.

Mary R Kwaan1, David M Studdert, Michael J Zinner

  • 1Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.

Archives of Surgery (Chicago, Ill. : 1960)
|April 19, 2006
PubMed
Summary

Wrong-site surgery is rare, occurring in about 1 in 112,994 operations. Current site-verification protocols could have prevented two-thirds of these preventable surgical errors.

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Area of Science:

  • Patient safety in surgical procedures.
  • Healthcare quality improvement initiatives.

Background:

  • Wrong-site surgery (WSS) remains a concern in healthcare.
  • Existing site-verification protocols aim to prevent surgical errors.

Purpose of the Study:

  • To determine the incidence and preventability of wrong-site surgery.
  • To evaluate the effectiveness of current site-verification protocols.

Main Methods:

  • Analysis of a case series of wrong-site surgery incidents reported to a malpractice insurer (1985-2004).
  • Survey of hospital site-verification protocols.
  • Assessment of protocol effectiveness under optimal conditions.

Main Results:

  • An incidence of 1 in 112,994 operations for non-spine wrong-site surgery was identified.

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  • Of 13 reviewed cases, 8 (62%) could have been prevented by the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol.
  • Protocol complexity varied significantly, with no clear added benefit in some cases.

    • Conclusions:

    • Wrong-site surgery is rare, and major injury from it is even rarer.
    • Current site-verification protocols have limitations in preventing all wrong-site surgeries.
    • Protocol design and implementation require further optimization for enhanced patient safety.