Incidence, patterns, and prevention of wrong-site surgery

Archives of Surgery
Mary KwaanAtul A Gawande

Abstract

We hypothesized that wrong-site surgery is infrequent and that a substantial proportion of such incidents are not preventable by current site-verification protocols. Case series and survey of site-verification protocols. Hospitals and a malpractice liability insurer. All wrong-site surgery cases reported to a large malpractice insurer between 1985 and 2004. Incidence, characteristics, and causes of wrong-site surgery and characteristics of site-verification protocols. 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 ...Continue Reading

Citations

Jul 4, 2008·Surgical Endoscopy·E G G VerdaasdonkJ Dankelman
Jul 12, 2014·International Orthopaedics·Reiner WirbelMarius Dehne
Aug 25, 2007·Annals of Surgery·John R ClarkeEdward D Finley
Mar 26, 2009·Annals of the Royal College of Surgeons of England·Geraint WilliamsJohn Gannon
Jul 3, 2009·Patient Safety in Surgery·Philip F StahelJeffrey Varnell
Oct 4, 2013·International Anesthesiology Clinics·Pascal FuchshuberMarc A Rozner
Mar 7, 2012·Surgical Infections·Nongyao KasatpibalPuangnipa Junthasopeepun
Mar 18, 2008·Plastic Surgical Nursing : Official Journal of the American Society of Plastic and Reconstructive Surgical Nurses·Kathleen Catalano
Jul 19, 2008·Surgical Endoscopy·E G G VerdaasdonkJ Dankelman
Apr 28, 2012·Surgical Endoscopy·Liane S FeldmanUNKNOWN FUSE (Fundamental Use of Surgical Energy™) Task Force
Jun 6, 2009·Der Unfallchirurg·C Lessing
Oct 8, 2013·Der Unfallchirurg·D EschmannU Schreiner
Oct 4, 2011·Neurosurgical Focus·Wesley HsuZiya L Gokaslan
Dec 31, 2009·Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery [et Al.]·Malcolm KeGary Lask
Dec 22, 2009·Journal of Neurosurgery·Robert R Cima
Apr 18, 2008·Nursing·Richard A Ridge
Feb 13, 2016·AJR. American Journal of Roentgenology·Soterios GyftopoulosLeora I Horwitz
May 31, 2014·AORN Journal·Charlotte L GuglielmiLinda K Groah
Jul 6, 2013·Journal of the American College of Radiology : JACR·Marianne T LuetmerDavid F Kallmes
Dec 22, 2012·Surgery·Winta T MehtsunMartin A Makary
Mar 20, 2013·Clinics in Plastic Surgery·Jennifer F Waljee, Kevin C Chung
Nov 21, 2012·Journal of Visceral Surgery·B RomainS Rohr
Nov 26, 2015·Anaesthesia·I K Moppett, S H Moppett
May 9, 2012·Journal of the American Academy of Dermatology·Shari A Nemeth, Naomi Lawrence
May 1, 2012·Journal of the American Academy of Dermatology·Kathleen M Rossy, Naomi Lawrence
Jan 25, 2012·The Surgical Clinics of North America·Michol Cooper, Martin A Makary
Sep 29, 2011·Surgery·Hiroshi YasuharaYushi Uetera
Oct 29, 2010·Annales Françaises D'anesthèsie Et De Rèanimation·J-M Malinovsky
Nov 3, 2010·Annales Françaises D'anesthèsie Et De Rèanimation·E PetrovaD Benhamou
Sep 16, 2008·AORN Journal·Kimberly Anne Dillon
Oct 29, 2008·Advances in Surgery·John R ClarkeDenise P Martindell
Oct 29, 2008·Journal of the American College of Surgeons·Wande PrattCharles M Vollmer
Jul 29, 2008·Journal of Vascular and Interventional Radiology : JVIR·John F AngleUNKNOWN Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery
Mar 27, 2007·Journal of the American College of Surgeons·Terry AltpeterHiram C Polk
Mar 27, 2007·Journal of the American College of Surgeons·F Dean GriffenKaren L Posner
Feb 13, 2007·AORN Journal·Suzanne C Beyea
Jan 27, 2007·Journal of the American College of Surgeons·Martin A MakaryPeter J Pronovost
Jun 3, 2009·BJU International·John Reynard, Howard Marsh
Jul 13, 2011·CA: a Cancer Journal for Clinicians·Mark R KatlicGlenn D Steele

❮ Previous
Next ❯

Related Concepts

Trending Feeds

COVID-19

Coronaviruses encompass a large family of viruses that cause the common cold as well as more serious diseases, such as the ongoing outbreak of coronavirus disease 2019 (COVID-19; formally known as 2019-nCoV). Coronaviruses can spread from animals to humans; symptoms include fever, cough, shortness of breath, and breathing difficulties; in more severe cases, infection can lead to death. This feed covers recent research on COVID-19.

Blastomycosis

Blastomycosis fungal infections spread through inhaling Blastomyces dermatitidis spores. Discover the latest research on blastomycosis fungal infections here.

Nuclear Pore Complex in ALS/FTD

Alterations in nucleocytoplasmic transport, controlled by the nuclear pore complex, may be involved in the pathomechanism underlying multiple neurodegenerative diseases including Amyotrophic Lateral Sclerosis and Frontotemporal Dementia. Here is the latest research on the nuclear pore complex in ALS and FTD.

Applications of Molecular Barcoding

The concept of molecular barcoding is that each original DNA or RNA molecule is attached to a unique sequence barcode. Sequence reads having different barcodes represent different original molecules, while sequence reads having the same barcode are results of PCR duplication from one original molecule. Discover the latest research on molecular barcoding here.

Chronic Fatigue Syndrome

Chronic fatigue syndrome is a disease characterized by unexplained disabling fatigue; the pathology of which is incompletely understood. Discover the latest research on chronic fatigue syndrome here.

Evolution of Pluripotency

Pluripotency refers to the ability of a cell to develop into three primary germ cell layers of the embryo. This feed focuses on the mechanisms that underlie the evolution of pluripotency. Here is the latest research.

Position Effect Variegation

Position Effect Variagation occurs when a gene is inactivated due to its positioning near heterochromatic regions within a chromosome. Discover the latest research on Position Effect Variagation here.

STING Receptor Agonists

Stimulator of IFN genes (STING) are a group of transmembrane proteins that are involved in the induction of type I interferon that is important in the innate immune response. The stimulation of STING has been an active area of research in the treatment of cancer and infectious diseases. Here is the latest research on STING receptor agonists.

Microbicide

Microbicides are products that can be applied to vaginal or rectal mucosal surfaces with the goal of preventing, or at least significantly reducing, the transmission of sexually transmitted infections. Here is the latest research on microbicides.

Related Papers

The New England Journal of Medicine
Alex B HaynesSafe Surgery Saves Lives Study Group
Journal of the American College of Surgeons
Martin A MakaryPeter J Pronovost
Annals of Surgery
John R ClarkeEdward D Finley
© 2022 Meta ULC. All rights reserved