October 1997 Bulletin

OK plan to end wrong-site surgeries

Academy seeks unified effort with surgical groups

The Academy will launch a major educational program among members in the months ahead to eliminate wrong-site surgery. The Academy also will enlist other surgical and health provider groups to implement effective controls to eliminate the problem in the U.S.

The Board of Directors approved an Advisory Statement Sept. 19, 1997 that includes a prevention protocol which will serve as the basis for the program. Developed by the Academy's Task Force on Wrong-Site Surgery, the prevention program will be highlighted at the Annual Meeting in New Orleans in March 1998 and will be included in continuing medical education programs and Academy communications.

S. Terry Canale, MD, Academy Board secretary who is chairman of the task force, told the Board of Directors that although the wrong-site surgery problem has been addressed on a local level in many areas of the country, there has been no national effort to eliminate the problem. The Canadian Orthopaedic Association mounted a significant educational program from 1994 to 1996 to eliminate the problem and the reported number of known wrong-site claims dropped dramatically.

Wrong-site surgery is a devastating problem that affects both the patient and surgeon. It's an issue that often results in newspaper headlines and provocative talk show discussions. The task force was formed to research the problem and find methods to prevent wrong-site surgery in orthopaedic patients and avoid possible disability.

However, wrong-site surgery is not just an orthopaedic problem that occurs because the surgeon operates on the wrong limb; it's a system problem that affects other surgical specialties. Operating on the wrong anatomical site is the result of poor preoperative planning, lack of institutional controls, failure by the surgeon to exercise due care or a simple mistake in communication between the patient and the surgeon.

Data on 110,000 physicians, represented by 22-member medical malpractice carriers of the Physicians Insurers Association of America (PIAA) for 1985 through 1995, showed there were 225 claims for orthopaedic wrong-site surgery. There were 106 similar claims for other surgical specialties. Claims involving wrong-site surgery constituted only 1.8 percent of the PIAA orthopaedic surgery claims for the period.

The median pay-out for wrong-site surgery was less for orthopaedic cases ($48,087) than other surgical specialties ($76,167). The data show that 84 percent of closed claims for wrong-site surgery resulted in payment, compared to only 30 percent of all other closed orthopaedic claims.

The task force also obtained detailed information from the State Volunteer Mutual Insurance Co. in Tennessee on 37 claims filed in the state from 1977 to 1997; 10 claims are still open. The age of the surgeons ranged from 33 to 73 years; the mean age was 46. The age of the patients at the time of surgery ranged from 12 to 90 years; the mean was 40.5 years. Thirty-six claims resulted from surgery in a hospital; one was at an outpatient surgery center.

Wrong-site surgery was most common in arthroscopic knee procedures in which the correct procedure was done, but on the wrong (contralateral) side. Foot procedures had the second highest frequency of wrong-site surgery.

The error was discovered during surgery in about 60 percent of the cases. In almost all of these cases, the planned anesthetic operation was carried out on the other, correct limb during the same anesthetic.

In most cases, the surgeon was in error or an incorrect site was prepared and draped by hospital staff. In a few cases, the patient may have given incorrect information or a documentation error was made either on the operative permit or on the preoperative radiographs.

Most patients had no residual deficit other than cosmetic, although there were additional medical expenses. There was impairment at the incorrect operative site in four cases; permanent disability, three cases; contracture, two cases; and nonunion, one case. The average loss of the 27 closed claims for wrong-site surgery was $33,000.

To prevent wrong-site surgery, the Advisory Statement recommends "having the surgeon's 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 surgeon's initials are placed on the operative site in a way that cannot be overlooked and in a manner that will be clearly incorrect if it transferred onto another body area prior to surgery. The patient's records also should be available in the operating facility."

In addition to Dr. Canale, chairman of the Task Force on Wrong-Site Surgery, other members are: Kristin Glavin, associate general counsel; Jesse C. DeLee, MD, program committee; Andrew J. Weiland, MD, Council on Education; Allen S. Edmunson, MD, Board of Directors, State Volunteer Mutual Insurance Co.; Steven S. Fountain, MD, chairman, Committee on Professional Liability; Lori Bartholomew, consultant, Physicians Insurers Association of America; Mark W. Wieting, Academy vice president, educational program. Ex-offico members are James D. Heckman, MD, Academy first vice president; and Richard H. Gelberman, MD, chairman, Council on Education.

Recommendations

Recommendations for management following wrong-site surgery:

A. 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

B. 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.

C. Local anesthesia

If the procedure is being performed under a local anesthesia and the patient is clearly able to comprehend what has occurred and is 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.

D. 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.

Editor's note: The Advisory Statement on Wrong-Site Surgery is on the Academy's home page at www.aaos.org in the "Library" section. The Advisory Statement also can be obtained by calling fax-on-demand (800) 999-2939. Order document number 1015.


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