Wrong Site Surgery

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he Joint Commission on Accreditation of Health Care Organizations on December 5, 2001 issued another alert on surgery mistakes. This is the second alert that the organization has issued in three years.

Surgery errors include operating on the wrong body part, the wrong person, or doing the wrong procedure.

Dr. Dennis O'Leary, president of the Joint Commission commented that these mistakes are completely avoidable. As a practicing surgeon, I would certainly agree with this opinion.

In 1995 a voluntary national database was created and since that time 150 cases have been reported. I would have to suspect that the number of cases nationally is many times that.

Statistics have shown that my specialty of Orthopaedic Surgery is responsible for over 40 percent of the wrong site surgery procedures. Neurosurgery is 14 percent and Urology is 11 percent.

Three fourths of the mistakes are procedures on the wrong body part. Eleven percent involved the wrong patient and eleven percent occurred when entirely the wrong operation was done.

The executive director of the American College of Surgeons, Dr. Thomas Russell observed that a well informed patient who is an active participant in his or her healthcare is going to have a better result.

Six years ago my orthopaedic academy, the American Academy of Orthopaedic Surgeons began a program to encourage members to either mark the correct site themselves when they see the patient preoperatively or to arrange for the patient or a family member to mark the correct site.

Unlike many other healthcare problems I believe that we know how to solve this problem. Mistakes are completely avoidable.

I would like to share with you what has worked very well for me over many years.

I insist that my patients remain awake in the operating room until I am able to personally see them and talk to them. I invariably have my office record with me in the operating room. I refer to it carefully before I approach the patient on the operating table. I look at the operating room schedule to verify how the case has been scheduled, which body part is to be operated upon, and which side is listed. I then go and speak to the patient addressing the patient by name and place my hands on the area that I'm going to operate upon. I briefly remind the patient of what I had previously said that I'm going to do in the surgery procedure.

Additionally, the operating room nurse greets the patient by name on arrival in the operating room and discusses with the patient what they understand the operation is going to be and which side.

I have found this to be a very effective way to avoid wrong site surgery, operating on the wrong patient, or doing the wrong operation on a particular patient.

This is obviously a very serious problem nationally and each surgeon and hospital has to institute a system that works for them. I know what works for me and I intend to continue to use it without exception.

The American Academy of Orthopaedic Surgeons has continued to be in the forefront of attempting to prevent wrong site surgery. The Academy believes that preventing wrong site surgery is a team effort that has many parts and to rely on a single preventive effort will only result in errors. The Academy has stated that one of the most promising new surgical procedures is performed with a felt tip marker. Of course this is referring to the patient or the physician marking the area to be operated upon with a permanent marking pen.

The American Academy of Orthopaedic Surgeons believes strongly that wrong site surgery can be eliminated in the United States by a unified effort among surgeons, hospitals, and other health care providers to initiate preoperative and other institutional regulations that would correctly identify the operative site.

In spinal surgery it becomes somewhat more complicated because the correct level of surgery must be identified. This is always known from preoperative x-ray studies, but at the time of surgery it can be confusing to know exactly what level you are looking at with the wound open.

On a personal note, having done spinal surgery since my orthopaedic surgery residency at the Cleveland Clinic I have invariably taken a x-ray in the operating room marking the exact site at which I felt the surgery was to be performed.

If the marker happens to be at a different level than the operative area this marker gives the proper orientation and the correct level can be easily identified.

The American Academy of Orthopaedic Surgeons also recommends that all of the patient's records should be available in the operating facility. I would agree with this completely because I have done this myself for many, many years. I find it actually much more important for me to have the patient's office record with me in the operating room because this give the entire patient story from the first time that I have seen the patient in the office and also covers subsequent visits. This combined with the hospital record of the patient that is generated on admission is enormously helpful in preventing wrong site surgery.

The problem of wrong site surgery is not going to go away and will always be a potential for disaster. We have made great strides in the last few years to reduce and possibly eliminate this problem, but our efforts need to be ongoing.