Orthopaedic Surgeons Issue Advisory on Wrong-Site Surgery

[Editor’s Note: Operating on the incorrect site or organ is a nontraditional patient safety problem, but one certainly worth considering because of the question of what role the anesthesia caregivers may have in verifying that the correct intended surgical procedure is about to take place. While this advisory was written for orthopedic surgeons, its concepts are also worth the consideration of the anesthesiology professionals involved.]

{short description of image}The APSF Booth in the 1999 ASA Meeting Exhibits provided a glittering array of digital and analog information.

Wrong-site surgery is a devastating problem that affects both the patient and surgeon and results from poor preoperative planning, lack of institutional controls, failure of the surgeon to exercise due care, or a simple mistake in communication between the patient and the surgeon.

Wrong-site surgery is not just an orthopaedic surgery problem that occurs because the surgeon operates on the wrong limb. This is a system problem that affects other surgical specialties as well. While the number of reported orthopaedic surgery cases is not high relative to the total number of orthopaedic professional liability insurance claims, a retrospective study of a sample of insurers across the country provides evidence that 84 percent of the cases involving wrong-site orthopaedic surgery claims resulted in indemnity payments over a 10-year period, compared to all other types of orthopaedic surgery claims where indemnity payments were made in 30 percent of orthopaedic surgery claims during this same time period.

Recommendations for Eliminating Wrong-Site Surgery Although the wrong-site surgery problem has been addressed on a local level in many areas of the country, there has been no organized national effort to eliminate wrong-site surgery. The Canadian Orthopaedic Association mounted a significant educational program from 1994-1996 to eliminate this problem and has reported that the number of known wrong-site orthopaedic surgery claims in Canada has subsequently dropped dramatically.

The American Academy of Orthopaedic Surgeons believes that a unified effort among surgeons, hospitals and other health care providers to initiate preoperative and other institutional regulations can effectively eliminate wrong-site surgery in the United States.

Consequently, the American Academy of Orthopaedic Surgeons urges other surgical and health care provider groups to join the effort in implementing effective controls to eliminate this system problem.

Effective Methods of Eliminating Wrong-Site Surgery Wrong-site surgery is preventable by having the surgeon’s initials placed on the operative site using a permanent marking pen and then operating through or adjacent to his or her initials. Spinal surgery done at the wrong level can be prevented with an intraoperative X-ray that marks the exact vertebral level (site) of surgery. Similarly, institutional protocols should include these recommendations and involve operating room nurses and technicians, hospital room committees, anesthesiologists, residents and other preoperative allied health personnel.

Consequently, eliminating wrong-site surgery means the surgeon’s initials are placed on the operative site in a way that cannot be overlooked and in a manner that will be clearly incorrect if transferred onto another body area prior to surgery. The patient’s records also should be available in the operating facility.

In keeping with its Code of Ethics, the Academy believes that in any communication with the patient or patient’s family regarding care rendered, particularly in relation to an untoward event such as wrong-site surgery, orthopaedic surgeons must be truthful in all circumstances.

As indicated in the attached recommendations, particular circumstances of individual cases require specific and different actions on the part of the surgeon in the event that wrong-site surgery is discovered, but in all cases the patient’s choice and the best interest of the patient should be the determining factors in decision-making. [Copies of the suggested strategies for a surgeon to deal with the discovery that wrong-site surgery has taken place are available from the American Academy of Orthopaedic Surgeons.]