New Protocols to Avoid Wrong-Site Surgeries

It seems inconceivable, but surgeons sometimes operate on the wrong side of a patient’s body. It is a horrible mistake that should never happen, but unfortunately it does. Nearly 40 patients across the U.S. each week will come out of surgery and learn that doctors operated on the wrong body part, wrong patient or that they completed the wrong procedure.

According to the Joint Commission Center for Transforming Healthcare, a healthcare accreditation body, wrong-site surgeries are still a problem even after the Commission set forth guidelines meant to prevent such errors nearly ten years ago.

The protocols included simple steps such as marking the areas for surgery, reviewing the procedures the patient would undergo and making sure that the correct patient was on the operating table. However, 93 wrong-site errors were reported in 2010, compared to only 49 in 2004.

Reporting such events is voluntary, so that doctors and hospitals would volunteer information in an effort to improve patient safety. So it is possible that a number of unreported errors occur. Philip F. Stahel, director of orthopedic surgery at Denver Health Medical Center, explained to Kaiser Health News that reported cases are “clearly the tip of the iceberg.”

The Joint Commission is currently testing its Targeted Solutions Tool, an application that enables hospitals to follow simple instructions at critical stages of the surgical process in order to minimize the risk of medical malpractice. In identifying its findings thus far, the Commission issued a preliminary report that identified key areas that create opportunities for errors, including:

  • Integrity of patient data – Researchers found that 39 percent of wrong-site surgeries are attributable to incomplete or inaccurate patient information, especially when surgical clinics and hospitals have vastly different ways of incorporating patient data.
  • Accuracy in surgical site marking – Researchers also found that surgical marks were not close enough to where incisions were to be made or were not clearly visible to the surgical team.
  • Site verification during the pre-operative stage – Documentation that confirmed the correct procedure and the proper area reduced the risk of wrong-site surgery from 52 percent to 19 percent.

The Joint Commission is working to make the Targeted Solutions Tool available to hospitals this fall. Hopefully tools such as this, along with increased awareness, will help to finally solve the problem of wrong-site surgeries.