Healthcare Delivery Problems: Wrong Site Surgery

March 24, 2011

By Kristin Simeons, Director of Healthcare Delivery Solutions

Wrong site surgery continues to be more prevalent than thought and without any consistent evidence of slowing. Research has repeatedly shown that these adverse events are largely underreported with compliance of physician reporting ranging from 5% to 50% - thus predicting true incidence of wrong site surgery to be hovering around 50 per week or 2600 events per year in the US alone. Costs beyond the obvious cardinal one of patient outcomes are multi-factorial for the healthcare system as well as the patient and reach into the millions.

Extensive research has proven that wrong site surgery results from several contributing factors.

Human Factors:

  • Heavy workload environment
  • Fatigue
  • Pressure to move quickly
  • Multiple and changing team members
  • Lack of accountability
  • Team communications

Patient Factors:

  • Patient not consulted prior to sedation
  • Patient confusion on site and side
  • Commonality among patient names

Procedure Factors:

  • Patient position or room change prior to initiating procedure
  • The sea of blue draping can mask patient position and anatomy
  • Similar procedures back-to -back-to –back
  • Cross- checking site/side data that is originated from the same source

What We Know

Even with strict adherence to the Universal Protocol, wrong site surgery has not decreased and continues to fall under national scrutiny…and additional checklists are not the answer.

Most of the work to date on remedying wrong site surgery has focused on activities that take place in the operating room (OR). As several patient safety experts have pointed out, little has been accomplished in studying and improving the steps leading up to the OR since The Joint Commission introduced its Universal Protocol in 2003. Moreover, the actual continuum of the patient journey from Pre-op to the OR has not been carefully examined. The data supports the need for additional work in these areas - 60% of wrong site surgery cases are rooted in either missteps or communication before and throughout the patient entering and transitioning to the OR.

What We Need To Know

Which staff is accountable during prep, before the team and patient enter the OR, and before the first incision is made – and how many of those staff members remain with the patient the whole time? Are pre-op activities and OR activities best aligned to mitigate the risk prone elements of the system?

Bottom line, hospitals need to deconstruct the entire patient journey - from the time the need for surgery is identified to the time the procedure takes place, in order to identify and resolve all the error prone activities that make up the surgical identification process.