Incidence, patterns, and prevention of wrong-site surgery.
OBJECTIVE
We hypothesized that wrong-site surgery is infrequent and that a substantial proportion of such incidents are not preventable by current site-verification protocols.


METHODS
Case series and survey of site-verification protocols.


METHODS
Hospitals and a malpractice liability insurer.


METHODS
All wrong-site surgery cases reported to a large malpractice insurer between 1985 and 2004.


METHODS
Incidence, characteristics, and causes of wrong-site surgery and characteristics of site-verification protocols.


RESULTS
Among 2,826,367 operations at insured institutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112,994 operations (95% confidence interval, 1 in 76,336 to 1 in 174,825). Medical records were available for review in 13 cases. Among reviewed claims, patient injury was permanent-significant in 1, temporary-major in 2, and temporary-minor or temporary-insignificant in 10. Under optimal conditions, the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol might have prevented 8 (62%) of 13 cases. Hospital protocol design varied significantly. The protocols mandated 2 to 4 personnel to perform 12 separate operative-site checks on average (range, 5-20). Five protocols required site marking in cases that involved nonmidline organs or structures; 6 required it in all cases.


CONCLUSIONS
Wrong-site surgery is unacceptable but exceedingly rare, and major injury from wrong-site surgery is even rarer. Current site-verification protocols could have prevented only two thirds of the examined cases. Many protocols involve considerable complexity without clear added benefit.
Kwaan
Mary R
MR
Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
Studdert
David M
DM
Zinner
Michael J
MJ
Gawande
Atul A
AA
D006801:Humans; D015994:Incidence; D008318:Malpractice; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data*; D011364:Professional Practice / Q000592:standards*; D017751:Safety Management; D013514:Surgical Procedures, Operative / Q000592:standards*