Once more, with feeling: Wrong-site surgery is still an unsolved problem

Joint Commission is losing patience with major errors

Wrong-site surgery is the kind of medical error that for a long time seemed so egregious that there was no need to directly address it with prevention efforts. No more. The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has issued its second alert in three years about wrong-site surgery and risk managers are starting to see the problem as needing real attention.

The tone of the Joint Commission alerts has changed and may indicate a new way of looking at providers who commit wrong-site surgery. The first alert of three years ago sought to draw attention to the problem without beating up providers too much for the mistake.

But in the second alert, president Dennis S. O’Leary, MD, sounds more like a frustrated parent who can’t believe he has to bring this up again.

"This concerned us because this is one of the few cases in which we have a second alert," he says. "The number of adverse events that we have reported to us each year is pretty much flat, about 400 cases a year. The number of wrong-site surgeries has gone up year after year."

In 1998 when the Joint Commission issued its first alert, there were 16 reports of wrong-site surgery. In 2001, there were 58. (For more on the analysis of past events see "Errors: What we have is a failure to communicate," in this issue.)

"That number has gotten higher each year, so we are becoming concerned about this," he says. "Health care experts are unanimous in their belief that these types of errors should never happen."

For risk managers, the financial cost of the mistakes will be a major concern. Aside from the media coverage and harm done to the patient, wrong-site surgery can cost a bundle. Physician Insurers Association of America in Rockville, MD, reports that 84% of wrong-site surgery claims against orthopedic surgeons and 68% against other physicians resulted in payment.

O’Leary says he does not think surgeons and risk managers are actively resisting the Joint Commission’s pleas to act on this problem, but "I think we are dealing with a lack of sense of urgency around this."

The Joint Commission’s most recent warning comes with support from the American College of Surgeons (ACS) and the American Academy of Orthopaedic Surgeons (AAOS). The three organizations jointly offer this advice for preventing wrong-site surgery:

  • Sign the operative site.

Having the surgeon actually write on the operative site reduces the chance of operating elsewhere.

  • Orally verify the surgery.

In the operating room just before starting the operation, each member of the surgical team should confirm that he or she has the correct patient, the correct surgical site and the correct procedure.

  • Take a "time out" in the operating room.

This gives the surgical team one last chance to double-check among themselves about the impending procedure, check charts, and corroborate information with the patient.

Most of the advice for preventing wrong-site surgery involves improved communication and careful, repeated verification of the patient’s identity, the planned procedure, and the exact surgical site. The AAOS recommends having the surgeon sign the operative site before surgery to confirm the proper site, but the idea has not been adopted widely enough for S. Terry Canale, MD, chief of staff and a member of the board of directors of the Campbell Clinic in Memphis, TN, and a past president of AAOS. Canale spearheads the AAOS campaign against wrong-site surgery. (For more advice see "Errors: What we have is a failure to communicate," in this issue.)

Risk managers should encourage surgeons to sign the surgical site at the time they visit with the patient before surgery, possibly the night before or first thing on the day of surgery, he suggests. Some surgeons have been doing that for several years now, but he says too many still think of it as being "overly cautious." The continuing problem shows that isn’t true, he says. After two years of encouraging its members to sign surgical sites, a survey found that only 60% were doing so. Canale says that is disappointing, since AAOS members probably are more aware of the problem than other surgeons.

O’Leary put his weight behind the recommendation as well. In a news conference after the most recent warning about wrong-site surgery, he stated: "Organizations should require that the surgical site be marked."

So, considering how most health care providers view the the Joint Commission’s advice, it’s not just a recommendation anymore.

Watch for problem in outpatient surgery, too

Canale says he uses an indelible pen from the Devon Pen Co. that leaves a mark for about eight days, even after a surgical scrub. He cautions risk managers to address the problem in outpatient surgery just as diligently.

"As a matter of fact, 70% now of all orthopedic surgery is done in outpatient surgery centers, and most of the wrong-site surgeries occur in orthopedic surgery because we’re dealing with two extremities."

Canale says risk managers must take action because if they don’t, wrong-site surgery is bound to occur in their organization sooner or later. An orthopedic surgeon practicing for 25 years has a 25% chance of making the error, he says.

"That means, basically, one in every four orthopedic surgeons is going to make that mistake in his career," he says.

Donald Palmisano, MD, JD, a surgeon and secretary-treasurer of the American Medical Association, and a commissioner on the Joint Commission, also endorsed the warning and suggestions for improvement.

"When I operate on the patient, I always go in the room and make sure the patient can see me," he says. "I do it for two reasons. I want to make sure it’s my patient and, second, I want the patient to have the comfort of knowing that I am there before they go to sleep."

Palmisano also encourages patients to get involved in the verification process. His wife recently had arthroscopic surgery by an orthopedic surgeon they trusted completely. But before she went into the operating room, Palmisano used a permanent marker to write: "This knee, Bob," and "Wrong side, Bob."

"No one gets offended by that and everybody said, You know, this is a safe thing to do,’" Palmisano says. "We must look at systems. We must eliminate shame and blame."

Thomas Russell, MD, ACS executive director, cautions that one should not allow surgeons to delegate the signing too much. It’s OK to have the patient do it, but the surgeon shouldn’t put the task off on someone else, he says.

"Some surgeons delegate it to a resident and some may delegate it to a nurse," he says. "The problem there is the further you delegate it away from the person who is responsible — the surgeon — the more the problem is going to jump up at you. Maybe if the surgeon has a resident he or she can count on and really knows the guy, that’s fine, but we really mean the surgeon should sign the site."