In this week’s Case Record of the Massachusetts General Hospital, a 65-year-old woman was admitted to the day-surgery unit for release of a trigger finger of the left ring finger. A carpal-tunnel release was performed. After the procedure, the surgeon realized he had performed the wrong operation.
Wrong-site surgery occurs in all surgical specialties but is most common among orthopedic surgeons and neurosurgeons, with 68% of claims in the United States related to orthopedic surgery.
• How common is wrong-site surgery?
In a 2003 survey of hand surgeons, 21% of the surgeons reported having operated on the wrong site at least once in their career, and 2% more than once. The number of cases documented by the Joint Commission has been increasing.
• What types of errors are most common?
A recent survey of orthopedic surgeons revealed that 5.6% of reported medical errors were wrong-site procedures or wrong procedures: of these, 59% involved the wrong side, 14% were wrong procedures, and 5% involved the wrong patient. The most common sites were the knee, the finger or hand, and the foot or ankle.
Table 1. Universal Protocol.
Morning Report Questions
Q: What is the universal protocol?
A: The universal protocol involves preoperative verification of the patient and the procedure, marking of the surgical site, and a time-out before the start of the operation.
Q: How should errors be managed?
A: The investigation of safety events requires a disciplined approach, as illustrated by this case. It begins with an analysis of contributing factors, which requires careful attention to three critical questions. What happened? Why did it happen? What can we do to prevent it from happening again? It is important to note that the question “Who was involved?” is not pertinent to future risk unless it is evidence of reckless behavior by the operator, which is rare and would require disciplinary action. Direct disclosure to patients and their families after an error salvages trust, decreases the likelihood of litigation, and facilitates the healing of both the patient and the provider. Disclosure and, when appropriate, apology and the waiving of fees are now accepted, and patients have come to expect them. In the aftermath of an event that seriously compromises safety, it is important not only to counteract the harm to the patient but also to care for the caregivers.