A medical record is simply a record of a patient's health and medical history. Depending on the level or need of care a patient has, records may vary, but all medical records will contain some common information.
The practice of medicine is advanced by self-reflection and a desire to improve the care of patients through the refinement of procedures and medical regimens. The first systematic record-keeping tool used for improving care was utilized in the late 1800s according to archived records of Cushing and Codman 1)
Between 2013 and 2020, there were 68 wrong-site closed claims cases. The mean age of the patients was 55.7 (standard deviation 16.21) years, and 51.5% were female. The services most frequently responsible for these were Orthopedic (35.3%), Neurosurgery (22.1%), and Urology (8.8%). The most common types of procedures were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%), and surgery on muscles/tendons (11.8%). The severity of claims was higher in the inpatient setting compared to the ambulatory setting. The most common alleged injuries included the need for additional surgery (45.6%), pain (33.8%), mobility dysfunction (10.3%), worsened injury (8.8%), death (7.4%), and total loss (7.4%). The top contributing factors to wrong-site surgery were failure to follow policy/protocol (83.8%) and failure to review the medical records (41.2%). The mean closed claim value was $136,452.84, and 60.3% of cases were settled.
The risk of wrong-site surgeries is increased with spine surgeries, likely due to unique technical challenges. Further research is required to identify effective methods of prevention of these events 2)