Wrong Site Surgery (WSS)-Preventable Errors

WEST DES MOINES, IA, June 12, 2013 (Press-News.org) The Problem

Wrong site surgery (WSS) includes surgery performed on the wrong side or site of the body, wrong surgical procedure performed, and surgery performed on the wrong patient. According to Dr. Mark R. Chassin, M.D., FACP, M.P.P., M.P.H, President, The Joint Commission, "Wrong site surgery is a rare event for individual surgeons or health care organizations. But when it does happen it is a devastating event that is often life altering for the patient who experiences it." Unfortunately, as noted by The Joint Commission, some estimates put the national incidence rate as high as 40 per week.

Potential Solutions

In recognition of the problems associated with WSS, The Joint Commission issued Sentinel Event Alert newsletters in 1998 and 2001, in an effort to call attention to this serious problem. In 2004, The Joint Commission convened a WSS summit that led to the development of a Universal Protocol. Use of the protocol is a prerequisite for accreditation by The Joint Commission. In February of 2012, The Joint Commission Center for Transforming Healthcare released its Targeted Solutions Tool (TST) for WSS. It is believed that use of the TST will increase the effectiveness of the Universal Protocol. According to The Joint Commission, over 50 professional associations and organizations have endorsed the Universal Protocol.

The three key elements of the Universal Protocol are: (1) preoperative verification process; (2) marking the operative site; and (3) taking a time out. In various publications, The Joint Commission Center for Transforming Healthcare has outlined specific causes for WSS procedures and identified specific recommendations to avoid and/or overcome these problems. For example, with respect to time out procedures, The Joint Commission Center for Transforming Healthcare recommends the following:

- Perform a standardized Time Out process, which occurs after the prep and drape, and includes the following elements:
- Perform role-based Time Out in which every team member has an active role to play in the process;
- Point and touch verification of the surgical site mark by the surgeon and scrub technician;
- Address any concerns by the team before proceeding; and
- Reduce noise and cease all other activity in operating room.

In recognition of the serious problems associated with WSS, the Iowa Board of Medicine specifically includes WSS as a grounds for disciplining Iowa physicians. Specifically, rule 653.23.1(45) provides as follows:
The board may impose any of the disciplinary sanctions set forth in 653-subrule 25.25(1), including civil penalties in an amount not to exceed $10,000, when the board determines that the licensee is guilty of any of the following acts or offenses:
. . .
(45) Performing or attempting to perform any surgical or invasive procedure on the wrong patient or at the wrong anatomical site or performing the wrong surgical procedure on a patient.

Your Rights

If you or a loved one are injured through a wrong site surgical procedure, you should consult an experienced medical malpractice attorney to review your rights, which would include filing suit against the negligent medical provider(s). While it is almost always necessary to present expert testimony to establish the applicable standard of care in a medical negligence case, one potential exception to this rule may, in the right case, be a wrong site surgery case.

1 The Joint Commission a not-for-profit organization, which accredits and certifies more than 20,000 health care organizations.

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