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Samuel C. Seiden, MD; Paul Barach, MD, MPH

Arch Surg. 2007;142(11):1112.

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In reply

The increased reporting trend of wrong-site surgeries or WSPEs (wrong-site, wrong-patient, wrong-procedure events) reported by the Joint Commission Sentinel Event database is, unfortunately, not unexpected. There are 2 challenges in interpreting this trend. The first is that the Joint Commission captures only a fraction of all occurrences of wrong-site surgery, perhaps as low as 2% of total US events, even though reporting of such events is mandated for all Joint Commission–accredited institutions. The second challenge relates to the increased awareness of WSPEs due to the Universal Protocol. This increased awareness may have correspondingly increased reporting while the incidence itself may have remained unchanged. We simply don't know. The data presented by Dr Croteau, and supported by our research,¹ suggest that these events continue to occur in spite of the Universal Protocol's dissemination and adoption. More is needed to prevent WSPEs.

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RELATED LETTER

Wrong-Site Surgeries Are Preventable
Richard J. Croteau
Arch Surg. 2007;142(11):1111-1112.
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Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events: Are They Preventable?
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