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Tuesday, March 16, 2000

Academy statement on wrong-site surgery

Wrong-site surgery is a devastating problem that affects both the patient and surgeon and results from poor preoperative planning, lack of institutional controls, failure of the surgeon to exercise due care, or a simple mistake in communication between the patient and the surgeon.

Wrong-site surgery is not just an orthopaedic surgery problem that occurs because the surgeon operates on the wrong limb. This is a system problem that affects other surgical specialties as well. While the number of reported orthopaedic surgery cases is not high relative to the total number of orthopaedic professional liability insurance claims, a retrospective study of a sample of insurers across the country provides evidence that 84 percent of the cases involving wrong-site orthopaedic surgery claims resulted in indemnity payments over a 10-year period, compared to all other types of orthopaedic surgery claims where indemnity payments were made in 30 percent of orthopaedic surgery claims during this same time period.

Recommendations for Eliminating Wrong-Site Surgery

Although the wrong-site surgery problem has been addressed on a local level in many areas of the country, there has been no organized national effort to eliminate wrong-site surgery. The Canadian Orthopaedic Association mounted a significant educational program from 1994-1996 to eliminate this problem and has reported that the number of known wrong-site orthopaedic surgery claims in Canada has subsequently dropped dramatically.

The American Academy of Orthopaedic Surgeons believes that a unified effort among surgeons, hospitals and other health care providers to initiate preoperative and other institutional regulations can effectively eliminate wrong-site surgery in the United States.

Consequently, the American Academy of Orthopaedic Surgeons urges other surgical and health care provider groups to join the effort in implementing effective controls to eliminate this system problem.

Effective Methods of Eliminating Wrong-Site Surgery

Wrong-site surgery is preventable by having the surgeonís initials placed on the operative site using a permanent marking pen and then operating through or adjacent to his or her initials. Spinal surgery done at the wrong level can be prevented with an intraoperative X-ray that marks the exact vertebral level (site) of surgery. Similarly, institutional protocols should include these recommendations and involve operating room nurses and technicians, hospital room committees, anesthesiologists, residents and other preoperative allied health personnel.

Consequently, eliminating wrong-site surgery means the surgeonís initials are placed on the operative site in a way that cannot be overlooked and in a manner that will be clearly incorrect if transferred onto another body area prior to surgery. The patientís records also should be available in the operating facility.

In keeping with its Code of Ethics, the Academy believes that in any communication with the patient or patientís family regarding care renderedóparticularly in relation to an untoward event such as wrong- site surgeryóorthopaedic surgeons must be truthful in all circumstances.

As indicated in the attached recommendations, particular circumstances of individual cases require specific and different actions on the part of the surgeon in the event that wrong-site surgery is discovered, but in all cases the patientís choice and the best interest of the patient should be the determining factors in decision-making.

September 1997

Appendix 1

Recommendations for Management
Following the Discovery of Wrong-Site Surgery
  1. General

    If, during the course of a surgical procedure, or after surgery has been completed, it is determined that the surgery is being or has been performed at the wrong site, the surgeon should always:

    1. act in accord with the patient's best interests and to promote the patient's well-being;

    2. record the events in appropriate medical records

  2. General Anesthesia

    If the procedure is being performed under general anesthesia, when it is determined that the surgery is being performed at the wrong site, the surgeon should:

    1. take appropriate steps to return the patient, as nearly as possible, to the patient's preoperative condition;

    2. perform the desired procedure at the correct site, unless there are medical reasons not to proceed. For example, if proceeding with the surgery at the correct site would materially increase the risk associated with extended length of the surgical procedure or if correct-site surgery would likely result in an additional and unacceptable disability;

    3. advise the patient, and the patient's family, if appropriate, as soon as reasonably possible, of what occurred and the likely consequences, if any, of the wrong-site surgery.

  3. Local Anesthesia

    If the procedure is being performed under a local anesthesia and the patient is clearly able to comprehend what has occurred and competent to exercise judgment, the surgeon should:

    1. take appropriate steps to return the patient, as nearly as possible, to the patient's preoperative condition;

    2. advise the patient of what has occurred, recommend to the patient what, in the surgeon's best judgment, is the appropriate course for the patient to follow under the circumstances; and

    3. truthfully answer any relevant question posed by the patient and then proceed as directed by the patient.

  4. Discovery after Surgery

    If, after the surgical procedure has been completed, it is determined that the surgery was performed at the wrong site, the surgeon should: as soon as reasonably possible, discuss the mistake with the patient and, if appropriate, with the patient's family and recommend an immediate plan to rectify the mistake unless there is a medical reason not to proceed.

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Last modified 23/February/2000 by IS