Commentary & Perspective

Commentary & Perspective on
"Incidence of Wrong-Site Surgery Among Hand Surgeons"
by Eric G. Meinberg, MD, and Peter J. Stern, MD

Commentary & Perspective by
James Herndon, MD*,
Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA

This article by Meinberg and Stern is important reading for all surgeons. It is the second article that has been published on this topic in The Journal during the last year, the first being a study of the results of a campaign to promote preoperative signing of the surgical site in Canada¹. It is alarming that even though "sign your site" programs provide a safe, easy method for eliminating this preventable error, wrong-site, wrong-procedure, and wrong-patient surgeries continue to occur. As Berke stated in Health Leaders magazine, "going in for surgery and receiving the procedure you were expecting seems like it should be a no-brainer"². In recognition of the continuing problem, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) recommends that all institutions create and use a preoperative verification process and implement a process that involves the patient in the marking of the surgical site. These recommendations became subject to survey in January 2003³.

Although the field of orthopaedic surgery has been the leader in identifying this problem and recommending a solution, the problem is far from corrected. In 1994, the Canadian Orthopaedic Association (COA) began an educational program to prevent such errors and recommended "marking the incision site with a permanent marker"¹ before the patient enters the operating room. Furey et al. surveyed 187 orthopaedic surgeons randomly selected from the COA membership list and, on the basis of the 167 responses that they received, reported on the effectiveness of this program. The surgeons were asked in the survey whether their hospitals had a preoperative surgical site-marking policy and how often they marked incision sites preoperatively. Sixty percent of the respondents reported that there was not a preoperative surgical site verification policy at their hospitals; 52% reported that they always marked the incision site; 23% reported that they occasionally marked the site; and 25% reported that they never marked the incision site. The most common reason given by those who never marked the incision site was confidence in their knowledge of the patient's condition. Further analysis revealed that those who had been in practice longer were less likely to mark the incision site. Of the forty-two surgeons who did not mark the incision site preoperatively, "57% had been in practice for more than twenty years"¹.

In 1997, the American Academy of Orthopaedic Surgeons (AAOS), stimulated by a perceived increase in wrong-site surgery in the United States, appointed a Task Force on Wrong-Site Surgery to determine the prevalence of wrong-site surgery and to develop recommendations regarding methods for its prevention. After reviewing the insurance records of 110,000 physicians of all surgical specialties during a ten-year period (1985-1995), the Task Force found 331 claims of wrong-site surgery, 225 of which involved orthopaedic surgery⁴. Although the findings of the Task Force indicated that the prevalence was low, it was still clear that wrong-site surgery is entirely preventable. For this reason, the Task Force recommended that surgeons identify the correct operative site with the patient and mark it with their initials preoperatively. The report of the Task Force on Wrong-Site Surgery was approved by the Academy's Board of Directors, and the AAOS issued an advisory statement entitled "Sign Your Site" in 1997.

The article by Meinberg and Stern in this issue of The Journal provides important information on the impact of the Academy's "Sign Your Site" campaign on hand surgeons. They reported that 70% of orthopaedic hand surgeons, in contrast with 25% of plastic hand surgeons and 36% of general hand surgeons, were aware of the Academy's campaign. However, only 45% of the orthopaedic hand surgeons who were aware of the "Sign Your Site" campaign had actually changed their practice habits as a result and signed the surgical site. As part of their survey, Meinberg and Stern also asked respondents to report voluntarily whether they had performed wrong-site surgery at any time. Of 1050 respondents, 217 (21%) reported having performed wrong-site surgery at least once during their career, with twenty-three surgeons (2%) reporting that they had done so twice and one surgeon (0.1%) reporting three incidents of wrong-site surgery. The authors also reported that a disturbing number of surgeons (173 [16%]) acknowledged a "near miss" in that they had prepared to operate on the wrong site but had caught their error before incision.

As part of their study, which involved hand surgeons, Meinberg and Stern also identified certain variables that were associated with the risk of performing wrong-site surgery: the risk increases with the surgeon's age and years in practice, and it is associated with an increased caseload. Interestingly, in their review of the surgical site marking program in Canada, Furey et al. also noted that surgeons who had been in practice longer were less likely to mark the surgical site preoperatively. Hopefully, these two publications have demonstrated that a cultural change is occurring and that younger surgeons are indeed marking their patients' surgical sites preoperatively at a higher rate than are older surgeons.

In addition to the voluntary efforts of our professional organizations to address the problem of wrong-site surgery, the Joint Commission on the Accreditation of Healthcare Organizations monitors the prevalence of wrong-site surgical errors, through the voluntary reporting of hospitals, patients, and the press, as part of their "Sentinel Event Alert" program. On the basis of these reports over the past seven years, the JCAHO has found that the problem is increasing rather than decreasing^5,6. The JCAHO received fifteen reports of wrong-site, wrong-patient, or wrong-procedure surgery in 1998. By December 1, 2001, there were 150 such reports.

With use of root cause analysis information, the JCAHO reported that in 126 of these 150 cases of surgical error, 76% involved the wrong body-part or site, 13% involved surgery on the wrong patient, and 11% involved performance of the wrong surgical procedure. According to this same analysis, 41% of the errors occurred in orthopaedic/podiatric surgery; 20%, in general surgery; 14%, in neurosurgery; 11%, in urologic surgery; and the remainder in dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgery. As a result of the increased number of wrong-site, wrong-patient, and wrong-procedure surgeries reported, the JCAHO issued a Sentinel Event Alert Advisory recommending that patients discuss the procedure and the site of their surgery with their medical team prior to undergoing surgical treatment⁵. Most recently, the JCAHO identified the elimination of "wrong-site, wrong-patient, wrong-procedure surgery" as one of their 2003 National Patient Safety Goals³. The JCAHO recommends that health-care organizations take the following actions:

1. "Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available, and

2. Implement a process to mark the surgical site and involve the patient in the marking process."³

In view of these recent recommendations by the JCAHO, the AAOS revised its advisory statement last year to emphasize that the patient and the physician together must discuss the procedure and the surgical site prior to surgery and, after that discussion, the surgeon is to sign the surgical site.

Although we cannot know for certain whether there has been an increase in wrong-site surgery in this country, a comparison of the voluntary data gathered by the JCAHO with the data gathered from mandatory reporting in the State of New York provides additional insight. Chassin and Becher⁷ compared the number of reports involving wrong-patient surgeries in the JCAHO database with that in the New York State database. The JCAHO received seventeen reports of an invasive surgical procedure performed on the wrong patient over a seven-year period, which indicates that an average of two to three patients per year were involved in such surgical errors. In contrast, the database of the State of New York, where mandatory reporting has been in place for some time, included twenty-seven reports of these errors over a forty-four-month period ending in 2001, an average of seven to eight patients per year. If these findings in New York are applicable throughout the United States, it is possible that only one-fourth of the actual number of wrong-patient surgeries are being reported to the JCAHO. These data provide a new view of the potential magnitude of the wrong-site surgery problem—a view that cannot be ignored.

It is difficult for me to understand why surgeons are reluctant to sign the surgical site. On the basis of both the study by Furey et al. and this study by Meinberg and Stern, it seems likely that about 70% of orthopaedic surgeons are aware of the AAOS "Sign Your Site" campaign but only about half actually routinely follow its recommendations. About 25% of orthopaedic surgeons use the program occasionally and about 25% never use it. Thus, while the AAOS campaign may be effective in communicating the problem and its solution, many surgeons have still not changed their practice habits accordingly. Given that the JCAHO identified elimination of wrong-site surgery as one of its six 2003 National Patient Safety Goals, it is unlikely that surgeons' compliance with this program will remain only a voluntary matter. While the New York State Department of Health now requires that surgeons verify in the perioperative area that the patient to be operated upon is the correct one, Florida's Board of Medicine has gone further by instituting penalties for wrong-site surgery in 2001. A physician can be fined up to $10,000 and be required to give a one-hour lecture to colleagues about his or her error. It is too early to tell if these measures are effective. Other regulatory agencies, such as the JCAHO, believe that punishing physicians for their errors will lead to underreporting of the data regarding surgical errors.

The American Academy of Orthopaedic Surgeons, the American College of Surgeons, and the Joint Commission on Accreditation of Healthcare Organizations all recommend that physicians involve their patients in the marking of the surgical site. These organizations further recommend that the surgical team in the operating room be educated about this program in order to achieve a heightened awareness of the problem. There should be a checklist that the surgical team uses to verify the type of surgery and to double-check that the patient in the perioperative area is the correct patient, the surgical procedure is the one scheduled for that patient, and the surgical site marked is the intended site for the operation. Now that health-care organizations are required to implement these guidelines for a comprehensive surgical site-marking program, there will be new pressure for surgeons to use the program.

Obviously, no surgeon wants to operate on the wrong patient or the wrong site, but the problem exists, and surgeons must take the lead to correct it. While we can debate the validity of various methods used to gather the data establishing the magnitude of the problem, we cannot escape the fact that the problem does exist. The "Sign Your Site" campaign is a straightforward program and following it takes only a minimal amount of time. It is the professional obligation of every surgeon to ensure that the correct patient receives the correct procedure at the correct site.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Furey A, Stone C, Martin R. Preoperative signing of the incision site in orthopaedic surgery in Canada. J Bone Joint Surg Am. 2002;84:1066-8.
2. Berke B. "X" marks the spot. Health Leaders. 2002;June:96.
3. Joint Commission on Accreditation of Healthcare Organizations. 2003 National Patient Safety Goals. Perspectives on Patient Safety. 2002;July:1-2. Available at: www.jcaho.org.
4. Cowell H. Editorial. Wrong-site surgery. J Bone Joint Surg Am. 1998;80:463.
5. Joint Commission on Accreditation of Healthcare Organizations. A follow-up review of wrong-site surgery. Sentinel Event Alert. December 5, 2001;Issue 24. Available at: www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_24.htm.
6. Beadling L. Increased wrong-site surgeries reported. Orthopedics Today. 2002;June:16-7.
7. Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:826-33.