“Wrong-site” surgery appears to be rare
By Megan Rauscher
NEW YORK (Reuters Health) – It’s a patient’s worst
nightmare — to wake up from surgery to find that the surgeon
has operated on the wrong organ or limb. It happens, but
thankfully not often, according to a new report.
The study also indicates that surgical “site-verification”
procedures designed to prevent so-called “wrong-site” surgery
are not always effective.
Wrong-site surgery includes procedures performed on the
wrong side of the body, the wrong body part, the wrong lesion
or growth, such as moles on the skin, the wrong vertebra of the
spine, or even the wrong patient.
“We learned that fortunately this kind of mistake is very
rare and only occurs one time in 113,000 operations,” Dr. Mary
R. Kwaan from Brigham and Women’s Hospital in Boston told
To be exact, there were 40 cases of wrong-site surgery
among a total of 2,826,367 operations performed in 30
Massachusetts hospitals between 1985 and 2004. The
investigators excluded cases involving the wrong spinal
vertebra, leaving 25 non-spine wrong-site operations, Kwaan and
her colleagues report in the Archives of Surgery.
Medical records were available for 13 of the non-spine
cases, and showed that one patient suffered a significant
permanent injury, two suffered major temporary injuries and 10
suffered minor temporary injuries.
When the researchers dug deeper into these 13 of cases,
they found that implementation of proper surgical procedures
would have prevented only eight of these mistakes (62 percent).
Hospitals are required by the Joint Commission on
Accreditation of Healthcare Organizations, the hospital
accrediting body, to verify the site and patient before
surgery; mark the surgical site on the patient; and take a
“time out” in the operating room before starting the procedure
to review the checklist.
“Patients should be aware that all hospitals are required
to have confirmation of the site and/or side of surgery on the
day of surgery,” Kwaan told Reuters Health.
“They can help facilitate this process of ‘double-checking’
by understanding what operation they are going to have. If they
are confused, they should ask their doctor to clarify it with
them – even that very morning of surgery,” Kwaan said.
Patients are always asked to sign a consent form, which
describes the planned procedure, at some point after the
decision is made for surgery. “They need to be able to
understand the description of the procedure, including what
exact part of the body is involved,” Kwaan said.
Still, “No protocol will prevent all cases,” she and her
associates write. “Therefore, it will ultimately remain the
surgeon’s responsibility to ensure the correct site of
operation in every case.”
SOURCE: Archives of Surgery April 2006.