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Understanding and preventing wrong-site surgeries

While surgeons in New York may not intend to make surgical errors, it is important to recognize that certain factors may create a greater possibility of issues such as wrong-site surgeries. Reporting of these errors to the Joint Commission increased from 15 incidents in 1998 to 592 in 2007, but an increase in voluntary reporting does not necessarily indicate an increase in the number of events. Such incidents are more likely in some practice areas; 20 percent of hand surgeons may commit such an error, and up to 25 percent of orthopedic surgeons might be involved in a wrong-site surgery.

Some of the most common causes of wrong-site medical errors include issues with leadership, noncompliance with established preventive procedures and failures in communication. Top risk factors tied to wrong-site surgeries can include changes in rooms for procedures, the use of unfamiliar or unusual equipment or setup, and patients' physical features such as deformities or obesity. Time pressures and emergency situations are also strongly connected to such errors. Complicating the surgery with multiple procedures or multiple surgeons at the same time could also play a role in an increased risk of surgical errors.

Efforts have been made at the national level to implement strategies for reducing and eliminating the problem of wrong-site surgery. One of these is Sign Your Site, which is used to identify the location of a surgery through communication with a patient and confirmed with a patient's signature. Medical professionals have developed additional protocols for preventing invasive procedures in the wrong place.

A patient may want to ask a physician about Sign Your Site and other preventive plans to reduce the risk of errors. Because a surgery on the wrong body part could have life-altering consequences, a patient who has experienced such an incident may want to consider filing a medical malpractice claim to address both financial and non-economic damages suffered.

Source: ahrq.gov, "Wrong-Site Surgery: A Preventable Medical Error ", Deborah F. Mulloy and Ronda G. Hughes, September 13, 2014

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