Getting off on the wrong foot doctor-patient miscommunication: a risk for wrong site surgery

Miscommunication between surgeon and patient can have far reaching consequences including the potential for wrong-site surgery (WSS). In the course of routine foot and ankle clinics, particular inconsistencies were noted between the terms used by surgeons and patients to label individual toes with the potential for miscommunication.

To investigate this phenomenon 100 consecutive patients were asked to label their own toes. The first fifty labelled their left foot, the subsequent fifty their right.

Errors in communication were common with an average frequency of greater than one in 10. Miscommunication was most likely when patients used numbers to label their toes, accounting for 93% of all errors.

As a result we recommend that healthcare professionals avoid the use of numbers to label toes when communicating with patients to help avoid miscommunication.