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Wrong-site surgery in orthopaedics.

P M Robinson¹, L T Muir

¹Department of Orthopaedics, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK. paulrobinson230979@yahoo.co.uk

The Journal of Bone and Joint Surgery. British Volume

|October 2, 2009

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Wrong-site surgery, including wrong-patient and wrong-procedure events, is more common than believed, particularly in orthopaedic surgery. Analysis of English and Welsh cases reveals a concerning incidence rate in this specialty.

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.

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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.