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In reply

We thank Dr Rothman for his letter. By reporting that wrong-site surgery is rare, we do not intend to rationalize this error nor de-emphasize efforts to prevent it. Wrong-site surgery remains unacceptable, and recognizing the incidence does not change this. Surgical teams have an enormous variety of potential errors to prevent—ranging from technical errors to technological malfunctions to retained instruments and sponges—and understanding their relative frequency is essential to planning effective interventions.

We agree that standardization of practices is an important strategy. However, what the best standard would be is unclear because rare errors are difficult to study and poorly understood. Contrary to Dr Rothman's assertions, we did find useful information about wrong-site surgery protocols implemented under recent guidelines from the Joint Commission on Accreditation of Healthcare Organizations. Among the 16 hospital site–verification protocols we studied, there was wide variation in the methods of site marking and in . . . [Full Text of this Article]

AUTHOR INFORMATION
Mary R. Kwaan, MD, MPH; David Studdert, LLB, ScD; Michael J. Zinner, MD; Atul A. Gawande, MD, MPH

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