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Study Finds Continued High Incidence of Surgery Performed on the Wrong Patient or on the Wrong Body Part

A Colorado study published late last year found that the incidence of surgeons operating on the wrong patient or at the wrong site is still high despite national efforts to improve compliance with the Universal Protocol, which specifies preprocedure verifications, surgical markings, and a "time out" before starting surgery.

Researchers found that over a six-and-half-year period, Colorado physicians reported 25 wrong-patient and 107 wrong-site procedures to a liability insurance database. The Universal Protocol has been in effect since 2004.

Failure to comply with one of the steps in the Protocol was the cause of the surgical error in a large number of the cases in the study. Interestingly, nonsurgeons were as likely as surgeons to be the cause of the error.

One death was reported when a patient died from acute respiratory failure due to wrong-sided placement of a chest tube.

Thirty eight patients suffered serious harm as a result of wrong-site procedures. These included:

  • Five wrong-level spine surgeries 
  • Four wrong-sided chest tube placements 
  • Four wrong-site vascular procedures 
  • Four wrong-part enterocolic resections 
  • Four wrong-organ resections 
  • Three wrong-site surgeries on the hand or elbow 
  • Three wrong-sided surgeries on the knee or foot 
  • Two wrong-sided ovariectomies 
  • Two wrong-sided eye surgeries 
  • Two wrong-sided craniotomies 
  • Two wrong-sided ureteric procedures 
  • One wrong-sided maxillofacial surgery 
  • Two cases of unintentional irradiation of an untargeted organ outside the oncologic radiation field

Five patients were seriously harmed by wrong-patient procedures:

  • Three prostatectomies performed on wrong patients secondary to mislabeling of biopsy samples
  • A vitrectomy on the wrong patient because two patients with the same names were coincidentally present in the office 
  • A myringotomy in a child scheduled for an adenoidectomy because the wrong patient was brought to the operating room

Click here to read more about the study on MedPage Today.

Learn more about wrong-site surgery

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