Wrong-Site Surgery
Wrong-Site Surgery
Incidence, Patterns, and Prevention of Wrong-Site Surgery
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA
Arch Surg. 2006;141:353-358
This report is based on 40 wrong-site surgery malpractice claims submitted to a large insurance company covering 30 Massachusetts hospitals over a 20-year period. During this period, approximately 2.8 million procedures (on both inpatients and outpatients) were performed in the study hospitals. Orthopaedic procedures (n = 11) and neurosurgical procedures (n = 12) were the most common specialties involved. The outcome was classified as permanent-significant in only 1 patient. For 5 of the 13 nonspine cases reviewed, the study authors believed that the "Universal Protocol" now required for all hospitals by the Joint Commission, would not have prevented the error.
This report gives quantitative data showing that wrong-site surgery is a rare event, and according to the study authors not always preventable by current preventive measures. It is far less frequent than retained foreign bodies, which lead to much more serious complications when they do occur. The overall responsibility for preventing wrong-site surgery resides with the surgeon who must ensure that the correct site is specified at the time of scheduling surgery.
Abstract
Incidence, Patterns, and Prevention of Wrong-Site Surgery
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA
Arch Surg. 2006;141:353-358
This report is based on 40 wrong-site surgery malpractice claims submitted to a large insurance company covering 30 Massachusetts hospitals over a 20-year period. During this period, approximately 2.8 million procedures (on both inpatients and outpatients) were performed in the study hospitals. Orthopaedic procedures (n = 11) and neurosurgical procedures (n = 12) were the most common specialties involved. The outcome was classified as permanent-significant in only 1 patient. For 5 of the 13 nonspine cases reviewed, the study authors believed that the "Universal Protocol" now required for all hospitals by the Joint Commission, would not have prevented the error.
This report gives quantitative data showing that wrong-site surgery is a rare event, and according to the study authors not always preventable by current preventive measures. It is far less frequent than retained foreign bodies, which lead to much more serious complications when they do occur. The overall responsibility for preventing wrong-site surgery resides with the surgeon who must ensure that the correct site is specified at the time of scheduling surgery.
Abstract
