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Warnken, LLC Attorneys at Law, Attorneys & Lawyers, Pikesville, MD

Wrong Site Surgery

Wrong-site surgery is a term usually used in describing operations on the wrong portion of the body, the wrong person, or the wrong level of vertebrae in the spine.  Mary R. Kwaan, et al., Incidence, Patterns, and Prevention of Wrong-Site Surgery, 141 Arch. Surg. (Apr. 2006), http://archsurg.ama-assn.org/cgi/reprint/141/4/353.  According to a 2003 finding by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 76% of wrong-site surgeries were surgeries performed on the wrong body part.  The remaining 24% was split between operations using the wrong procedure or operations on the wrong person.  Kwaan at 353.  In response to the occurrence of wrong-site surgeries, JCAHO implemented a universal protocol that has been followed by all accredited hospitals since 2004.  Id.

In this study conducted by the Department of Surgery at Brigham and Women’s Hospital and the Department of Health Policy and Management at Harvard School of Public Health, 28 hospitals were profiled to determine the commonality of wrong-site surgeries.  Id. at 354.  Out of 1,153 malpractice claims from these hospital records, there were 40 incidents of wrong-site surgery.  Out of the 40 cases of wrong-site surgeries, 62% of them were surgeries not involving spinal vertebrae.  Id. at 354.  The most common non-spinal wrong-site surgery occurred in adult, inpatient, and orthopedic operations.  Id. at 355 (Table 1).  Over a 19-year interval (1985 to 2004) these 28 hospitals had a rate of about 1 in 112,994 non-spinal, wrong-site surgeries.  Id. at 354.  Of these non-spinal, wrong-site surgeries, 46% produced only temporary and insignificant results for the patient.  Id. at 355 (Table 3).  The results of the study yielded a prediction that only once in five to ten years a major hospital would have an incident of wrong-site surgery resulting in a lawsuit.  Id. at 356.  Overall, this 2006 study looking at multiple hospitals concluded that wrong-site surgeries were generally rare.

A more recent study, reported in the Annals of Surgery, reports different results on the prevalence of wrong-site surgery.  The conclusion reached by this group of doctors determined wrong-site surgery occurs on a more regular basis and needs to be addressed beyond the protocols provided by the Joint Commission on Accreditation of Healthcare Organizations.   John R. Clarke, et al., Getting Surgery Right, 246 Annals of Surg. At 395 (Sept. 2007), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/pdf/20070900s00006p395.pdf.

Overall prevalence of wrong-site surgeries, however, is difficult to calculate accurately.

It is difficult to determine a true incidence, not only because of the lack of a standard threshold for what constitutes wrong-site surgery and documented under-reporting by healthcare providers, but also because the denominator of potential opportunities for each of the distinct wrong-site errors is unknown.

Clarke at 396.  This study analyzed reports of the Pennsylvania Patient Safety Authority over the course of 30 months, from June 2004 until December 2006.  According to these reports, 70% of wrong-site surgeries were wrong-side surgeries.  Id. at 397.  Approximately 30% of 334 reported wrong-site surgeries involved the legs.  Wrong-site surgeries on the head or neck comprised 24%, while pelvic surgeries constituted 21%, arm surgeries 14%, and lumbar structures 7%.  Id. at 397-8.  The results of this study yielded a prediction that a wrong-site surgery will happen about once a year per major hospital.  Id. at 399.  This is a drastic change from the previous study’s prediction of one incident per five to ten years.

If you have had an issue with this type of medical malpractice, please contact Warnken, LLC at 443-921-1100.  Wrong site suregry or wrong side surgery can be devastating to a person, a family, and a life.