Wrong Site Surgery


Wrong-site surgery (WSS) is the quintessential medical error. It is preventable, it bears the risk of serious adverse outcome and it is almost always the result of systems failure.

Prior to the Deficit Reduction Act of 2005 which required patient safety indicator reporting and more recently the Affordable Care Act of 2010, the United States lacked a coordinated national response to hospital acquired conditions. It was left to the individual states to initate ad hoc tracking and risk reduction programs.

In 1985, the Florida Legislature required licensed hospital and ambulatory surgical centers to report irreparable injuries to the Division of Health Quality within the Florida Agency for Health Care Administration (AHCA).

Agency for Health Care Administration - Reportable Hospital Code 15 Injury Category Totals
Period Death Fetal Death Brain Damage Spinal Damage Wrong site surgery Wrong patient surgery Wrong surgical procedure Procedure unrelated to diagnosis Removal surgical foreign object Repair of surgical injury

2012

130 6 23 11 33 6 10 101 84 57
2015 126 12 27 4 35 6 7 138 101 28

In 2003, Minnesota began a its mandatory adverse health event reporting system.

Adverse Health Events in Minnesota 2016 PUBLIC REPORT
WRONG SITE SURGERIES/INVASIVE PROCEDURES, 2009-2015
2009
2010
2011
2012
2013
2014
2015
27
31
24
27
17
16
29

The following checklist may help familiarize non-OR personnel with some of the processes used by surgical teams to reduce wrong-site surgery. This outline is not comprehensive and does not include any diagnosis or procedure specific considerations. Every institution should have a Surgical Safety Check List. Depending on policy the Surgical Checklist may not be part of the permanent Medical Record. It should capture the following information for the purpose of continuous quality improvement.

The foregoing procedures are intended to identify and eliminate risk before the patient experiences harm. Every identified risk, large and small, is an opportunity for the system to improve provided that an incident report documents the relevant information.

Wrong-site surgery occurs because: organizational leadership is lacking, procedural steps are skipped, team members are exchanged, schedules are altered, etc. Each team member must sustain a culture of safety even under emergency conditions. The false economy of short-cuts must be repudiated. Patient safety first and last!


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