Feature Story

AHRQ study finds wrong-site surgery is rare and preventable

"Wrong-site surgery" includes surgery on the wrong organ or limb, at the wrong site on the spine, or on the wrong person. Wrong-site surgery is extremely rare, and major injury related to it is even more rare, according to a study supported by the Agency for Healthcare Research and Quality (HS11886).

Researchers estimate that a wrong-site surgery serious enough to result in a report to insurance risk managers or in a lawsuit would occur approximately once every 5 to 10 years at a single large hospital. The study assessed all wrong-site surgeries reported to a large medical malpractice insurer between 1985 and 2004 and found that the number of wrong-site surgeries conducted on limbs or organs other than the spine occurred once in every 112,994 operations. Forty cases of wrong-site surgery were identified among 1,153 malpractice claims and 259 instances of insurance loss related to surgical care. Twenty-five of the cases were non-spine wrong-site surgeries, with the remainder involving surgery of the spine.

The study examined site-verification protocols at 25 hospitals as a means to prevent wrong-site surgery from occurring. Site-verification protocols, procedural safeguards that involve patient and surgeon communication, could include:

1. Marking the part of the body where surgery is to occur.
2. A pre-operative verification process by the surgeon and one other health care staff member.
3. Resolution of inconsistencies by the surgeon.
4. Informed consent from the patient with specification of the site of the surgery.

The study found that simplicity and avoidance of excessive redundancy are the key features of successful site-verification protocols.

Available medical records for 13 of the 25 non-spine wrong-site surgery cases show that injury was temporary and minor in 10 of the cases. Researchers conclude that following the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery might have prevented eight of the cases.

See "Incidence, Patterns and Prevention of Wrong Site Surgery," by Mary R. Kwan, M.D., M.P.H., David M. Studdert, L.L.B., Sc.D., Michael J. Zinner, M.D., and Atul A. Gawande, M.D., M.P.H., in the April 2006 Archives of Surgery 141, pp. 353-358.

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