Wrong site surgery-where are we and what is the next step?

Area of Science:

• Patient Safety
• Surgical Quality Improvement
• Healthcare Management

Background:

• Wrong-site surgery occurs approximately 40 times weekly in US healthcare facilities.
• The Joint Commission implemented the universal protocol to combat wrong-site, wrong-procedure, and wrong-person surgeries.
• Despite protocols, data indicate no improvement and potentially worsening trends in surgical errors.

Purpose of the Study:

• To evaluate the effectiveness of the current universal protocol for preventing surgical errors.
• To identify weaknesses in the existing surgical safety procedures.
• To propose improvements for a more effective surgical error prevention system.

Main Methods:

• Analysis of existing data on wrong-site surgery incidence.
• Review of the universal protocol's components: preoperative verification, site marking, and time-out.
• Examination of World Health Organization recommendations and literature on surgical safety.

Main Results:

• Current data show no progress in reducing wrong-site, wrong-procedure, or wrong-person surgeries.
• The reliance on surgical team memory within the current protocol is identified as a critical failure point.
• Existing strategies are insufficient to prevent surgical errors effectively.

Conclusions:

• The universal protocol, as currently implemented, is not adequately preventing surgical errors.
• A process dependent on memory is inherently unreliable for ensuring surgical safety.
• Enhanced, in-depth checklists, informed by WHO guidelines and identified weaknesses, are recommended to create a more foolproof system against wrong-site procedures.