WRONG SITE SURGERY

Wrong Site Surgery

Wrong Site Surgery

Surgical site marking has been recommended to prevent wrong site surgery (WSS). According to Universal Protocol promulgated by Joint Commission on Accreditation of Healthcare Organizations (JCAHO), mark must be made using an indelible marker that is sufficiently permanent to remain visible after completion of skin preparation. However, in clinical practice, one skin marker always is non-sterile & used on several patients. Therefore, in theory, there is the risk of contamination of surgical site from the surgical marker. We hypothesize that surgical site marking used by marker which is non-sterile & reused on multiple patients, may affect surgical preparation & potentially contaminate surgical field. After the review of available evidences, we conclude that surgical site marking does not affect sterility of surgical field. Surgeons should be more confident in confirming preoperative marking as an effective component in preventing WSS.

Although healthcare reporting databases suggest that these sentinel events are infrequent, to public any such occurrence is shocking & undermines confidence in healthcare system. Sentinel events are unexpected incidents that involve serious physical or psychological injury or prolonged loss of function or even death. These results are not present at time patient seeks healthcare & are not related to patient's underlying condition. Deficiencies in healthcare systems or processes are considered major contributors to sentinel events. Joint Commission uses term “sentinel” because it signals need for immediate response & investigation. Retained foreign bodies, medication errors resulting in patient harm, & wrong-site surgery are sentinel events reported to Joint Commission. Wrong-site surgery is one of worst sentinel events experienced by patients & practitioners.

Several terms are used for “wrong-site surgery” including “wrong-site, wrong-side, wrong-procedure, wrong-patient surgery” & abbreviated “wrong-site surgery.” As defined by Joint Commission, wrong site surgery involves wrong side or site of body, wrong procedure (the procedure other than intended), or wrong patient.

High-Pressure, High-Stress

Healthcare system is increasingly complex, with multiple systems & organizational factors that create opportunities for “near misses,” adverse events, & sentinel events. perioperative area is the high-pressure, high-stress environment that requires the high level of communication & teamwork. Joint Commission has identified communication problems between surgical team members & patient & family as major factors in sentinel events.4 surgical patient's care spans many areas ( surgeon's office, facility's scheduling office, preoperative unit, OR, & PACU) & involves many care providers & the variety of tools & technology. 

Joint Commission has monitored sentinel event statistics since 1995. Wrong-site surgery is second most commonly reported sentinel event, accounting for 13%.4 Several studies in recent years provide more in-depth analysis.5-7 In one study that reviewed medical cases with malpractice claims, number of wrong-site surgeries was greater than number of transfusion errors & cases of retained foreign bodies.6 Errors involving side or site are reported most frequently (76% of wrong site surgery in Joint Commission data) & are influenced by laterality, bilateral symmetry, & paired structures.4,7 It's not surprising then, that orthopedics is specialty with greatest reported errors. In one database study, sites of errors included knees, hips, foot/ankle, & ...