Wrong-Site Surgery

Abstract

The Joint Commission initiated its sentinel event policy in 1995 as a method to identify and track leading causes of medical errors and unexpected deaths within the United States. Wrong-site surgical (WSS) procedures ranked the highest among 4074 sentinel events reported to the Joint Commission between January 1995 and December 2006. Factors that have been shown to increase the risk for wrong-site surgery and invasive procedures include comorbid and bilateral disease, morbid obesity or physical deformity, incomplete or inaccurate communication, poor booking processes, unusual time pressures, emergency procedures, and the need for multiple procedures or multiple surgeons. In 2004, the Joint Commission implemented its “Universal Protocol” procedure in an effort to reduce the incidence of wrong-site and wrong-patient procedures. The protocol mandates that a three-step process be performed before the start of any invasive procedure or surgery. The three steps include a verification process, marking of the operative site, and a final time out process to re-confirm the right patient, the right procedure, and the right site/side. Prevention of WSS is more complex than anticipated and it’s been shown that use of the Universal Protocol is not enough to eliminate wrong-site procedures. Prevention strategies include strict adherence to the protocol, good teamwork, and aggressive education of all employees in the risk factors and root causes for these events. Future prevention strategies need to go beyond addressing the human factors if we are to achieve zero wrong-site events.