“First do no harm.” Patients undergo operative procedures with the inherent belief that their surgeon will perform the operation in a safe and effective manner, and, certainly, on the correct organ or body part. However, recent data suggest that in orthopaedic surgery alone, 21% of hand surgeons, 50% of spine surgeons, and 8.3% of knee surgeons have performed wrong-site surgery at least once during their career. These are astonishing numbers! Orthopaedic surgeons are at increased risk of performing wrong-site surgery, mainly because of the inherent nature of the musculoskeletal system. Anatomic factors such as laterality, multiple digits, and different spinal levels predispose to wrong-site surgery. Despite the importance of this problem, the incidence of wrong-site surgery in orthopaedics is unknown, primarily because of the lack of data regarding the exact numbers of operative procedures performed.
In this month’s issue of JBJS Reviews, Santiesteban et al. reviewed wrong-site surgery and the history of the development of procedures and practices to avoid it in orthopaedic surgery. Their research shows that, in 1994, the Canadian Orthopaedic Association was the first orthopaedic organization to introduce a surgical safety program designed to reduce wrong-site surgery, known as “Operate Through Your Initials.” Soon thereafter, in 1997, the American Academy of Orthopaedic Surgeons (AAOS) appointed a task force on wrong-site surgery, and, in 1998, the AAOS introduced “Sign Your Site,” a national surgical safety campaign distributed to all hospitals in the United States. By 2004, The Joint Commission became involved and introduced the Universal Protocol, requiring its use for Joint Commission recertification. This protocol recommends the use of three standardized preoperative safety components for every surgical procedure by every surgical team: (1) proper patient identification, (2) marking of the surgical site, and (3) use of a time-out procedure prior to the incision. Wrong-site surgery is preventable, as this initiative was meant to show.
It remains unclear how effective the various adopted methods (including improved consent procedures between the physician and patient, preoperative signing of the appropriate surgical site, time-out protocols, and postoperative debriefings) have been at decreasing the rate of wrong-site surgery. Indeed, it was more than a decade ago that the development of new protocols designed to prevent wrong-site surgery were implemented. Although these protocols have been adopted in most operating rooms, wrong-site surgery and adverse events continue to occur on a weekly basis.
Wrong-site surgery remains a rare but preventable catastrophic surgical event. As noted, the true incidence is unknown. As many as one in four orthopaedic surgeons will perform wrong-site surgery during an active twenty-five-year surgical career, and orthopaedic spine surgeons appear to be at highest risk. Surgeon leadership, commitment, and vigilance are critical to improve surgical patient safety. By adopting these initiatives, wrong-site surgery can be prevented.
Thomas Einhorn, MD
Editor, JBJS Reviews
I cannot agree with the word “preventable” used in the wrong-site surgery article in JBJS Reviews to which Dr. Einhorn refers in this Editor’s Choice because it is not consistent with the evidence. The dictionary definition of “prevent” is “to stop something from happening, make impossible.” The evidence, and common sense, suggest that wrong-site surgery rates can be reduced but not completely “prevented.” This distinction is critically important partially due to the legal environment in which we live which tends to conclude that IF something is “preventable,” THEN its occurrence equates to malpractice with associated liability.
The volume of procedures performed, anatomic variability, and level of specificity as to what constitutes “wrong-site” likely make total elimination of wrong-site surgery impossible. There are millions of operations performed across the country. There are some cases of “wrong-site surgery” that are clear. Others are more subtle. Consider, for example, a case of spine surgery in a patient with a congenital hemi-vertebra where determination of level of spinal elements and nerve roots can lead to uncertainty as to the level of instrumentation or decompression that may meet legal criteria of “wrong-site surgery.”
Surgeons should recognize the factors that lead to this problem and implement strategies like “time-out” and “sign the site” that seem to help. Continued research is appropriate to identify the most effective strategies. I support the efforts to minimize the incidence of “wrong site surgery” but the literature does not support the notion that wrong site surgery is entirely “preventable” from a society perspective.
These admirable efforts to advance operating room safety must be paired with a total commitment by senior staff; both physicians and nurses. Habits die hard and bad habits are the worst! Leaders must continue to model safe behaviors even in the face of volume pressures inherent in today’s busy medical practices.
When I finished my residency in 1978, our graduating class was told that before we would be done practicing, one in three of us would do a wrong site surgery. Determined to avoid that pitfall, I began marking the correct extremity. I was reported to the hospital CEO by nursing staff for this idiosyncracy. He told me that this showed lack of confidence, it was outside the norm, and I was asked to stop. I retorted by asking if I could paint the correct extremity with betadine “to prevent infection”. That was accepted. I am happy that now both practices are considered the ‘standard of care’!