Preventing Wrong Site Surgery

Dec. 6, 2001 -- If you needed surgery on your right knee, would you be confident that your surgeon would not mistakenly operate on the left?

An alert issued Wednesday by the Joint Commission on Accreditation of Healthcare Organizations said that since 1996, more than 150 cases of "wrong site" surgeries — when surgeons operate on the wrong body part or wrong patient or perform the wrong procedure — have been collected by its error reporting database.

Perhaps the most notorious case of wrong site surgery involved Willie King, who in 1995 went into a Tampa, Fla., hospital for surgery to amputate one foot badly afflicted by gangrene but had the wrong foot removed instead.

"The number of wrong site surgeries has gone up year after year after year, so we are becoming concerned about this," said JCAHO President Dr. Dennis O'Leary at a teleconference held Wednesday.

Representatives from the American College of Surgeons, the American Academy of Orthopaedic Surgeons and the American Medical Association also participated in the teleconference and lent their support to the JCAHO alert.

Why Mistakes Occur

While experts assert that these instances are rare, they can be an added cause for concern for patients who are facing surgical procedures.

"This is a very important issue, because today in hospitals we are working under a great stress with large volumes of patients," Dr. Thomas Russell, executive director of the American College of Surgeons, said at Wednesday's teleconference.

High patient volume can mean that surgeons and other members of a surgical team have less time to spend with individual patients, and to effectively communicate with them and with each other.

"Surgery is a team effort and the team is working in a system — it's not just one person who is doing all of this. The team can only work if the systems around you in the hospital or in an ambulatory unit are properly working," said Russell.

Communication, say the experts, is a key element to preventing the systems breakdowns that are the root cause of many of these surgical errors.

Patient Control and Prevention

Patients, too, play a role in preventing these kind of surgical errors, experts say.

"A very important member of the team is the patient," said Russell. "I think that patients today must not feel intimidated. They must feel free to ask questions, they must be involved with the providers."

JCAHO recommends patients take a more active role in their surgeries. Patients should:

Discuss specifically what will be done during the surgery with both the surgeon and anesthesiologist.

Have your surgical site marked with a permanent marker in the presence of their surgeon, then have your surgeon initial the site. This is also known as "signing the site."

Medical experts feel that these simple steps will go a long way in avoiding the complex problem of wrong site surgery.

"Some complications in surgery and medicine may not be preventable," said Dr. S. Terrence Canale, immediate past president of the American Academy of Orthopaedic Surgeons and member of the teleconference panel. "But whether this is a complication or error, operating on the wrong site is completely preventable ... by doing the 'sign your site' program.

"And if the surgeon won't do it, the patient ought to demand that [they] do it," Canale added.