“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