Special Feature: Wrong Site Surgery is Rare

Debra: The idea of needing surgery and having the wrong part operated on makes most people very nervous. But the good news is that surgery on the wrong site is extremely rare, and even when it does occur, major injury from it is even rarer. The term wrong-site surgery includes surgery on the wrong organ or limb, at the wrong site on the spine, or on the wrong person. A new study, led by Dr. Mary R. Kwaan, a surgical researcher at the Brigham and Women’s Hospital Center for Surgery and Public Health in Boston, estimates 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. Dr. Kwann is with us now to talk about her research. Dr. Kwann, thank you for being with us. What is the main take away message from your study?

Dr. Kwaan: I think there are a couple points that are highlighted by our study. The first and the most important one is that wrong site surgery is an exceedingly rare problem. And the second point, I think, is of interest is that wrong site surgery has a variety of different types of problems involved. The cases that we identified were not all cases of operating on the wrong side of the body, but a good portion of them involved operating on the wrong structure for example, the wrong finger or toe operating on the wrong lesion, if there are multiple lesions for example, removing the incorrect mole. And so, because of the diversity of wrong site surgery, I think it makes it a little bit harder to think about the best approach to prevention. So that was the second finding, and the third finding is, I think, that the nature of injury for wrong site surgery cases was also, thankfully, only involved major injuries in three of the thirteen cases that we reviewed. The majority of cases involve temporary or permanent minor injury, meaning usually a scar. So those are things to keep in mind when thinking about wrong site surgery.

Debra: What led you to look at this issue?

Dr. Kwaan: Well, we were pointed to the issue by the JCAHO, or the Joint Commission on Accreditation of Healthcare Organizations new universal protocol. At the time our study began, they were considering making universal protocol requirements for all accredited hospitals, and that went into effect in July of 2004. The universal protocol is a system that occurs just before surgery to prevent wrong site surgery and there are three main features of that protocol. The first is marking the operative site, meaning pen to skin with either the surgeons initials or a yes to indicate what the site of operation is going to be. The second component of the universal protocol is the pre-operative verification process, where various patient documents and medical records are compared with the way the surgical procedure is scheduled and booked and that comparison is made both by the surgeon and the nurse or other healthcare providers involved in the pre-operative planning process. And the third component of the universal protocol is a time-out in the operating room, really in the minutes before performing the surgical procedures. So we noted this universal protocol and our question was, what is the problem that is being addressed with the universal protocol and how likely is it that this protocol is going to catch cases of potential wrong site surgery? That is why we went ahead to see if we could find some cases in amongst the twenty years of malpractice cases that were available to us to review.

Debra: Your research says that very few wrong site surgeries were serious enough to result in a lawsuit. What happened to the people who had minor injuries from their surgeries?

Dr. Kwaan: In those situations, usually what happened was, the error was made, the operation was performed on the wrong site, but the disability that was suffered was that the patient had a scar where they did not plan or intend to have a scar. Obviously, its unacceptable that this sort of error is made, but our point was, we wanted to see if any life-threatening injury was sustained in cases of wrong site surgery, and we found that no lives were lost and that permanent, significant or major injury was not the result in the majority of cases.

Debra: Even though there weren’t that many wrong site surgeries, your study said many of the ones you found could have been prevented.

Dr. Kwaan: That’s correct. Our study, as I mentioned earlier, involved looking at wrong site surgeries over a twenty year time period. Certainly, many of these cases pre-dated the universal protocol and so what we thought to do was to look at our current requirement from the JCAHO and ask the question if this protocol was diligently enforced, would any of the cases that we identified over the twenty year period have been preventable? On the plus side, we found that the majority of cases probably would have been prevented by a simple checking procedure. However, we also found that some cases would not have been prevented by even the most diligently enforced protocol that happens on the day of surgery. And with this in mind, we noted that probably there is no protocol that’s going to prevent every single case, and ultimately, the responsibility for preventing this problem does fall into the hands of the surgeon who decides which procedure is indicated and decides to operate on the patient.

Debra: Finally, Dr. Kwaan, what can patients do to make sure they are operated on correctly?

Dr. Kwaan: I think that’s a very important question. To set the context for that question, about what patients can do to prevent a wrong site surgery, we have to step back and say this is a very uncommon problem, and that this type of adverse outcome really is one of the least likely problems that the patients going to encounter when coming to a hospital for surgery. So that’s the context of the problem. The second thing is that its good for patients to be aware that we have a universal protocol where, on the day of surgery, there will be people asking them what side the surgery is going to be performed, if they know what the procedure is. So patients should not be alarmed when they’re asked questions like that, or when we mark the site of surgery. This is all part of a patient safety protocol to prevent errors. And then, third, for the patients to prevent wrong site surgery, I think, generally, what’s going to be most useful is if patients understand what sort of procedure they’re going to have when they present for surgery. This means that they understand what site side of the body is going to be operated upon, what part of the body really is involved, what the goal of the procedure is. They should have a basic understanding of that, and if they don’t understand that, or if their family members don’t understand that, its probably wise for them to continue to ask what exactly they’re going to have, even if its on the day of surgery. They’re always asked to sign a consent form that describes the basics of what procedure they are going to have and this is, again, another point in the pre-operative planning process where they can make a point to try and understand what procedure is planned for them.

Debra: Dr. Kwaan, thank you so much for your time today.

Dr. Kwaan: No problem, thank you.

Debra: Dr. Kwan’s study on wrong-site surgery is in the April issue of Archives of Surgery.