Wrong-site surgery
Reducing wrong-site surgery is fundamental to safe, high-quality care.
The implementation of a universal surgical safety checklist protocol in 2004 was intended to minimize the prevalence of wrong site surgery (WSS). However, complete elimination of WSS in the operating room continues to be a challenge.
A follow-up study examining 8 years of reported surgical adverse events and root causes from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events.
This quality improvement study described patient safety adverse events and close calls reported from 86 VHA medical centers from the approximately 130 VHA facilities with a surgical program. The surgical procedures and programs vary in size and complexity from small rural centers to large, complex urban facilities. Procedures occurring between January 1, 2010, and December 31, 2017, were included. Data analysis took place in 2018.
The categories of incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room, adverse events or close calls, surgical specialty, and harm. These results were compared with the previous studies of VHA-reported wrong-site surgery (2001-2006 and 2006-2009).
The review produced 483 reports (277 adverse events and 206 close calls). The rate of in-operating room (in-OR) reported adverse events with harm has continued to trend downward from 1.74 to 0.47 reported adverse events with harm per 100 000 procedures between 2000 and 2017 based on 6 591 986 in-OR procedures. When in-OR events were examined by discipline as a rate, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10 000 cases. The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10 000 procedures based on 3 234 514 in-OR procedures. The most common root cause for adverse events was related to issues in performing a comprehensive time-out (28.4%). In these cases, the time-out either was conducted incorrectly or was incomplete in some way.
Over the period studied, the VHA identified a decrease in the rate of reported adverse events in the OR associated with harm and continued reporting of adverse event close calls. Organizational efforts continue to examine root cause analysis reports, promulgate lessons learned, and enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences 1).
Groff et al. noted that almost 50% of reporting surgeons had performed wrong-level lumbar spine surgery at least once in their practice. While such a survey has not been performed in patients undergoing surgery for thoracic and upper lumbar intradural tumors, it is reasonable to expect that in a small but substantial number of such patients, a wrong-level exposure has been performed. The incidence of wrong-level surgery is likely to be higher for patients undergoing a minimally invasive technique such as a hemilaminectomy or hemilaminotomy 2).
The purpose of a study was to evaluate the prevalence and etiology of WSS in the state of California. Study Design A retrospective study of all WSS reports investigated by the California Department of Public Health between 2007 and 2014.
Prevalence of overall and specialty-specific WSS, causative factors, and recommendations on further improvement are discussed.
A total of 95 cases resulted in incident reports to the California Department of Public Health and were included in the study. The most common errors were operating on the wrong side of the patient's body (n = 60, 62%), performing the wrong procedure (n = 21, 21%), operating on the wrong body part (n = 12, 12%), and operating on the wrong patient (n = 2, 2%). WSS was most prevalent in orthopedic surgery (n = 33, 35%), followed by general surgery (n = 26, 27%) and neurosurgery (n = 16, 17%). All 3 otolaryngology WSS cases in California are associated with the ear.
WSS continues to surface despite national efforts to decrease its prevalence. Future research could establish best practices to avoid these “never events” in otolaryngology and other surgical specialties 3).
Risk factors
The risk of wrong-site surgeries is increased with spine surgery, likely due to unique technical challenges. Further research is required to identify effective methods of prevention of these events 4)