“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
Eighteen percent of nearly 400 orthopaedic surgeons responding to an 89-question survey about patient safety said they do not perceive a positive climate for patient safety in their organizations. In the July 15, 2015 JBJS, authors Janssen et al. call that percentage “high when compared with the [10%] threshold for highly reliable organizations.” Perceptions of patient safety were higher among men, surgeons in non-teaching hospitals, and those working in hospitals with a safety program already in place.
The authors surmise that the perception of a better patient-safety climate in non-teaching hospitals may be attributable to less complex care requirements that permit “a more structured approach,” and to typically smaller institution sizes in which care providers are “more adapted to each other and work more as a team.”
The respondents said that orthopaedic surgeons themselves are mainly responsible for preventing wrong-site surgery and retained foreign bodies. The most commonly cited strategies for improving patient safety overall were:
- Making safety everyone’s responsibility
- Improving communication, and
- Standardizing procedures, equipment, and supplies.
Interestingly, surgeons who received salaries not linked to procedure volume were more enthusiastic about safety programs than those who received fee-for-service compensation. Janssen et al. conclude that “knowledge of the variation in perceived safety and the enthusiasm for specific strategies to improve safety among surgeons can serve as a starting point for necessary cultural change.”