You may have heard about outrage over the recent report of a Kenyan physician performing brain surgery on the wrong patient. You can read more about it here. This is a pretty extreme example of a wrong site/wrong patient surgical error, and one of the types of “never events” my partner wrote about last week. Unfortunately, wrong site/wrong patient surgery events like this occur everywhere, not just in the third world.
The incidence of wrong site/wrong patient surgeries in the United States is difficult to pin down because there are no mandatory reporting requirements. Fear of litigation and of poor rankings among health care providers, as well as the refusal of insurers to pay for harm caused by wrong site/wrong patient surgery, actually provide a reporting disincentive.
Current studies estimate wrong site surgery occurs between about 1 in 27,000 and 1 in 110,000 procedures. On the bright side, since the Joint Commission on Accreditation of Healthcare Organizations began to shine light on the problem in 1998, reports of wrong site surgery incidents have increased from 15 in 1998 to over 1500 in 2015. During this time, several groups have devised systems and procedures which have built upon one another to address the problem.
For example the American Academy of Orthopedic Surgeons encourages surgeons to “sign” the correct surgical site, while also marking the incorrect site (i.e. “Not This Leg”). The Joint Commission developed a three-step Universal Protocol involving (1) preoperative verification, (2) marking the operative site and (3) then taking a time out to verify the correct site again. The American Association of periOperative Nurses developed a Correct Surgery Tool Kit, including an education program, pocket reference guides for ensuring the identification of the correct surgery site, a copy of the Joint Commission’s Universal Protocol, and guidelines for developing additional protocols to address and prevent wrong site surgical procedures.
Surprisingly, there may not be much patients themselves can do to prevent wrong site surgery occurrences. One group of experimenters for example found that among patients asked to identify a foot or ankle on which surgery was to be performed, 40% marked the wrong one. You can take some steps to avoid wrong patient surgery by telling everyone who will listen who you are and what surgery you are to have.
Ultimately, the surgeon is responsible for operating on the correct body part in the correct patient. But, he or she needs systems in place to make sure that happens. While those systems continue to be developed here in the U.S., until universal reporting of never events like wrong site/wrong patient surgeries is implemented, it will be difficult to gauge their effectiveness.
