Not an Urban Myth
For many years, I regarded wrong-site surgery as
urban mythology. In my mind, both were tales of appalling
events that had never happened; they were fiction,
complete fabrication, never authentic. On April 1,
1984, a friend told me about his uncle, a successful
businessman and, despite blindness in one eye secondary
to a childhood injury, top-notch golfer who twice
had been the Wisconsin amateur champion. Because the
blind eye had become painfully diseased, his uncle
agreed to its surgical removal. After surgery he awoke
to total darkness and asked where he was. The surgeon
answered, “Mr. ______, I made a terrible mistake.”
I promptly told my friend that he had terrible taste
in his choice of April Fool’s pranks. Sadly
this gut-wrenching story was true.
Wrong-site surgery is not urban mythology. Although
measuring its true incidence is elusive, it occurs
with distressing, preventable frequency. A 1997 American
Academy of Orthopaedic Surgeons (AAOS) task force
estimates that an orthopedic surgeon has a 1-in-4
chance of performing a wrong-site operation in a 35-year
career. From January 1995 to May 2003, 11.8 percent
of 2,034 sentinel events investigated by the Joint
Commission on Accreditation of Healthcare Organizations
(JCAHO) were wrong-site operations. The ratio of self-reported
cases to nonself-reported cases was 1:2. The New York
State Department of Health received reports of 46
wrong-site surgeries during the first two years of
mandatory reporting. Estimates of the number of cases
range from 200 to 1,000 cases per year in the United
States.
Factors associated with wrong-site surgery are listed
in the table. Note that incompetence and malevolence
are not factors. Wrong-site surgery is a systems problem.
It is a preventable error that requires a team approach.
The name/blame/shame technique of the past will not
work.
Organized medicine in the United States has undertaken
initiatives to prevent this tragic complication. Since
the mid 1990s, AAOS has promoted its “Sign Your
Site” and “Pause for the Cause”
programs to the profession and the public. In October
2002, the American College of Surgeons (ACS) Board
of Regents approved guidelines for avoidance of wrong-site
surgery. It requires the surgeon to mark the surgical
site in the case of a bilateral organ, limb or anatomic
site prior to the patient being given narcotics,
sedation or anesthesia and to conduct a final
verification process with members of the surgical
team to confirm the correct patient, procedure and
surgical site. Among its other requirements is verification
that the correct procedure is recorded on the operating
room schedule and that the correct patient is taken
to the operating room. The full statement was published
in the December 2002 Bulletin of the American
College of Surgeons.
On May 9, 2003, I was privileged to represent ASA
at a Summit Conference on Wrong-Site Surgery sponsored
by JCAHO, ACS AAOS, the American Medical Association,
the American Hospital Association, the American College
of Physicians and the American Dental Association.
More than 40 organizations participated in the development
of strategies to prevent wrong-site surgery. The product
of this meeting resulted in the Universal Protocol™
announced in a JCAHO December 2, 2003, press release
that addresses:
1. Preoperative verification process
2. Marking the operative site
3. “Time-Out” for surgical team to make
sure all members agree upon the identity of the
patient, procedure and site.
The JCAHO press release and Universal Protocol™
are available on the ASA Web site at <www.ASAhq.org/news/jcahoalert120403.htm>
and are covered in detail in this issue’s “Practice
Management” column. A more thorough discussion
of incidence and contributing factors can be found
in the 2003 ASA Annual Meeting Abstract #A-1355 authored
by Samuel C. Seiden, a medical student who participated
in the JCAHO summit.
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