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O U T P A T I E N T S U R G E R Y M A G A Z I N E O N L I N E | J U LY 2 0 1 5
Are you marking the surgical site right? Our survey
shows too much variability and plenty of room for improvement.
N
o one knows exactly how often a surgeon cuts into
the wrong body part, but wrong-sided surgery hap-
pens more often than you think, affecting hundreds
of patients a year, sometimes with horrific conse-
quences. In one widely
publicized Florida case a few years ago,
a series of mistakes by the OR team
resulted in a doctor amputating the
wrong leg. Hundreds more cases likely go unreported. A study in the
Archives of Surgery (osmag.net/Tv8kUC) that says wrong-site surgery
is underestimated by a factor of 20 or more estimates that there are
1,300 to 2,700 wrong-site procedures annually in the United States. A
recent study in the JAMA Surgery (osmag.net/s9WSHq) suggests that
it's about 1 in every 100,000 procedures. Wrong-site surgery is clearly
closer to an everyday event than a "never event." And for that, we
have inadequate site marking at least partially to blame. Either it's
not being done or it's not being done as it should.
Never ending?
The Joint Commission has a set of guidelines for surgical facilities to
follow to prevent wrong-site surgery: verify the surgical procedure to
be performed, mark the surgical site in advance and take a "time out"
immediately before starting the operation, during which team mem-
bers verify that they've got the right patient and that they've marked
the surgical site. It's been 11 years since the Joint Commission imple-
Jim Burger
Associate Editor
