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Incidence, Patterns, and Prevention of Wrong Site Surgery

Mary R Kwaan1, David Studdert2, Michael J. Zinner1, Atul A. Gawande1
1Brigham and Women's Hospital, Boston, MA;2Harvard School of Public Health, Boston, MA

Objective: To estimate the incidence of wrong-site surgery and to compare characteristics of cases with protocols designed to prevent them.
Design: (1) Case series. (2) Survey of site-verification protocols.
Setting: Hospitals.
Patients and other participants: (1) All wrong-site surgery cases reported to a large malpractice insurer between 1985 and 2004. (2) Site-verification protocols in place in 2004 at 16 hospitals covered by three malpractice insurers in three states.
Main Outcome Measure(s): (1) Incidence, characteristics, and causes of wrong-site surgery, (2) Characteristics of site-verification protocols.
Results: Among 2,826,367 operations at insured institutions during the study period, 25 cases of non-spine wrong-site surgery were identified, an incidence of 1 in 117,765 operations (95%CI, 1:78934 to 1:175698). Eighteen (72%) prompted malpractice claims, 13 of which were available for review. Among reviewed claims, patient injury was permanent-significant in one, temporary-major in two, minor in ten (77%). Under optimal conditions, the JCAHO Universal Protocol might have prevented 8/13 (62%) cases. Hospital protocol design varied significantly, mandating 2 to 4 personnel to perform 12 separate operative-site checks on average (range 5 to 20). Five protocols required site-marking in cases involving non-midline organs/structures; six required it in all cases.
Conclusions: Wrong-site surgery is unacceptable but very rare and major injury even rarer. Publicized cases may exaggerate perceived incidence and harm. Site-verification protocols vary, and many require significant personnel time for multiple redundant checks. Simplification of protocols would improve efficiency and allow surgical teams to focus limited time and energy on prevention of more common or harmful errors.

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