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Incidence, Patterns, and Prevention of Wrong-Site Surgery
Mary R. Kwaan, MD, MPH;
David M. Studdert, LLB, ScD;
Michael J. Zinner, MD;
Atul A. Gawande, MD, MPH
Arch Surg. 2006;141:353-358.
Hypothesis We hypothesized that wrong-site surgery is infrequent and that a substantial proportion of such incidents are not preventable by current site-verification protocols.
Design Case series and survey of site-verification protocols.
Setting Hospitals and a malpractice liability insurer.
Patients and Other Participants All wrong-site surgery cases reported to a large malpractice insurer between 1985 and 2004.
Main Outcome Measures Incidence, characteristics, and causes of wrong-site surgery and characteristics of site-verification protocols.
Results Among 2 826 367 operations at insured institutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112 994 operations (95% confidence interval, 1 in 76 336 to 1 in 174 825). Medical records were available for review in 13 cases. Among reviewed claims, patient injury was permanent-significant in 1, temporary-major in 2, and temporary-minor or temporary-insignificant in 10. Under optimal conditions, the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol might have prevented 8 (62%) of 13 cases. Hospital protocol design varied significantly. The protocols mandated 2 to 4 personnel to perform 12 separate operative-site checks on average (range, 5-20). Five protocols required site marking in cases that involved nonmidline organs or structures; 6 required it in all cases.
Conclusions Wrong-site surgery is unacceptable but exceedingly rare, and major injury from wrong-site surgery is even rarer. Current site-verification protocols could have prevented only two thirds of the examined cases. Many protocols involve considerable complexity without clear added benefit.
Author Affiliations: Department of Surgery, Brigham and Women's Hospital (Drs Kwaan, Zinner, and Gawande), and Department of Health Policy and Management, Harvard School of Public Health (Drs Kwaan, Studdert, and Gawande), Boston, Mass.
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