Wrong Site Surgery Increases After the Introduction of the Universal Protocol

A study of more than 27,370 adverse events self-reported by Colorado physicians and published in the October Archives of Surgery found that 132 wrong-patient and wrong-site procedures were reported to the Colorado Physician Insurance Co. from 2002 to 2008.

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 18,000 health care organizations and programs in the United States. In 2004 the Joint Commission mandated a three-step protocol requiring physicians and other health professionals to perform a pre-procedure verification process, mark the correct site for the procedure and conduct a “timeout” discussion as a final check before the procedure begins.

In an unexpected finding the study found that peak annual numbers of reports for both categories occurred after the commission’s protocol was implemented. This is not due to a flaw in the protocol but a reflection of the fact that it is not followed rigorously.

The procedure problem is not limited to the operating room. A quarter of wrong-patient cases reported in the Archives of Surgery study involved internists, and 32% of all the incorrect procedures involved nonsurgical specialists such as radiologists and dermatologists. The one death reported was due to a chest tube being placed on the incorrect side, causing acute respiratory failure. Thirty-four patients were significantly harmed or impaired according to the study.

The Joint Commission has published a brochure for patients to help them avoid mistakes in their surgery. The brochure suggests that patients prepare a list of questions to ask their doctors concerning the surgery in the pre-operative meeting. Patients should also read the consent form to ensure that it correctly identifies them and the kind of surgery to be performed.

Before the surgery a health care professional will mark the spot to be operated on. The patient should make sure that only the correct part is marked. This helps to avoid mistakes. If the patient cannot be awake for the marking then a family member or friend or another health care worker can watch the marking to make sure the correct body part is marked.

More information concerning the frequency of medical error can be found on our medical adverse event studies page.

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