Incorrect Surgical Procedures Within and Outside of the Operating Room

Authors:
  • PMPeter D. Mills
    Peter D. Mills
  • NENoel Eldridge
    Noel Eldridge
  • EDEdward J. Dunn
    Edward J. Dunn
  • CSCarol Samples
    Carol Samples
  • JTJames R. Turner
    James R. Turner
  • ARAudrey Revere
    Audrey Revere
  • RDRalph G. DePalma
    Ralph G. DePalma
  • JBJames P. Bagian
    James P. Bagian
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Abstract
Incorrect surgical procedures can be devastating. Some examples include wrong-site,1 wrong-side, wrong-procedure, or wrong-patient events.2 Based on the database analysis of Seiden and Barach,2 we estimated that 5 to 10 of these events occur daily in the United States. A report from Pennsylvania stated that some aspect of an actual or close-call wrong-site surgical procedure occurs every other day in that state.3 Kwaan et al1 examined a malpractice insurance database for wrong-site surgical procedures and estimated an incidence of 1 in 112 994 nonspine, wrong-site surgical procedures. That study did not include wrong-patient or wrong-procedure events and excluded non–operating room (OR) cases, so it is understandable that this rate appears lower than that reported by Seiden and Barach. The New York Patient Occurrence and Reporting Tracking System database, for which reporting is mandatory, indicated 100 or more wrong-patient, wrong-site, and wrong–invasive procedure events reported per year in that state for 2003-2005.4 Wrong-site surgical procedure was the sentinel event most frequently reported to The Joint Commission.5 The literature indicates that the true incidence of incorrect surgical procedures is not known with confidence. Despite efforts to eliminate incorrect surgical procedures, these events continue to occur.3,5-7

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