Wrong Site Surgery

When a surgeon operates on the wrong limb, the patient often sustains a devastating injury. Wrong site surgery occurs not only on the wrong limb or organ but on the wrong patient. This error results from numerous breakdowns in the hospital's system, including poor preoperative planning, a lack of institutional controls, the failure of the surgeon to exercise due care, or poor communication between the surgeon and the patient.

The serious nature of the problem has led the American Academy of Orthopedic Surgeons (AAOS) to urge all surgical and healthcare providers to join in its effort to implement effective controls to eliminate his problem for both inpatient and outpatient procedures. Institutional protocols should involve not only surgeons but also operating room nurses and technicians, hospital room committees, anesthesiologists, residents, and any other postoperative healthcare personnel.

One effective method used to prevent wrong site surgery is to have the surgeon, in consultation with patient if possible, place his or her initials on the operative site using a permanent marker that will not wash off when the area is sterilized. The placement of the initials should be in a location that cannot be overlooked even after the patient is prepped and draped for surgery. Initials or the word "yes" are preferred over an "X," which could be confusing. In addition, the patient's records should be readily available in the operating room.

In the operating room, the surgeon and all members of his or her team, including the anesthesiologist, the circulating nurse, and the scrub nurse, should pause to confirm the patient's identity, the correct procedure, site, equipment, and any implants or devises to be inserted during the procedure. Medical records and x-rays should be double-checked as belonging to the patient. Any missing or conflicting information should be clarified before the procedure in started.

The AAOS has created a protocol for surgeons to follow if it is determined that the surgery is or was performed on the wrong site. The emphasis in these procedures is on conduct that is in the patient's best interest and that promotes the patient's well being. The problem must be recorded in the patient's medical records.

If the surgeon discovers that he or she has operated on the wrong site during the procedure and the patient is under general anesthesia, he should take any appropriate steps to restore the patient to his preoperative condition. The surgeon should then perform the desired procedure on the correct site unless there are medical reasons not to proceed. These reasons might include a materially increased risk due to the length of the surgery or a determination that correct site surgery would likely result in an additional and unacceptable disability. The surgeon is obligated to inform the patient and his or her family of the problem and to truthfully answer their questions regarding the event and the likely consequences of the wrong site surgery.

If the patient is under local anesthesia and can clearly understand the situation and make competent decisions, he or she should be advised of the problem. The surgeon should recommend the appropriate course to follow, truthfully answer any of the patient's questions, and proceed according to the patient's directions.

When the surgeon does not discover the error until after the procedure has been completed, he or she is ethically required to discuss the mistake with the patient as soon as is reasonably possible and to recommend a plan to rectify the situation unless there is a medical reason not to proceed.