Wrong-site surgery in orthopaedics

Area of Science:

• Patient Safety
• Surgical Quality Improvement
• Healthcare Management

Background:

• Wrong-site, wrong-procedure, and wrong-patient events are serious adverse events in healthcare.
• Existing evidence suggests these events occur more frequently than commonly perceived.
• The increasing volume and complexity of surgical procedures may contribute to a rise in such errors.

Purpose of the Study:

• To review the literature on wrong-site surgery.
• To analyze data on wrong-site surgery cases in England and Wales.
• To identify the incidence and characteristics of wrong-site surgery, with a focus on orthopaedic surgery.

Main Methods:

• Systematic review of existing literature on wrong-site surgery.
• Analysis of data from the National Patient Safety Agency and NHS Litigation Authority.
• Examination of 292 cases of wrong-site surgery in England and Wales between 2006 and 2007.

Main Results:

• Orthopaedic surgery accounted for 29.8% (87 cases) of the analyzed wrong-site surgery events.
• The estimated rate of wrong-site surgery in England and Wales from 2006 to 2007 was highest in orthopaedic surgery at 1:105,712 cases.
• Wrong-site surgery represents a significant patient safety concern across various surgical specialties.

Conclusions:

• Wrong-site surgery is a more prevalent issue than often acknowledged.
• Orthopaedic surgery presents a disproportionately high rate of wrong-site events compared to other specialties.
• Continued vigilance and improved safety protocols are crucial to mitigate wrong-site surgical errors.