Wrong-Site Surgery – A Never Event That Still Occurs

Wrong-site surgery (WSS), operating on the incorrect body part, is a terrifying medical error classified as a “never event” by healthcare organizations. Despite its severity and potential for devastating consequences, WSS persists in the healthcare system. 

According to the National Institutes of Health (NIH), the incidence of WSS ranges from 0.09 to a concerning 4.5 per 10,000 operations in the US alone. The Joint Commission’s 2022 report on sentinel events identifies it as the fourth most significant preventable problem plaguing healthcare. 

Beyond the physical and emotional toll on patients, WSS creates a substantial economic burden. A study revealed a staggering $1.3 billion in payouts for surgical never events, including WSS, over two decades. 

These statistics paint a grim picture of the human cost and financial strain of this preventable error.

This article discusses the reasons why wrong-site surgery persists. We’ll explore strategies to prevent its occurrence and empower patients to advocate for their safety during surgery.

The Devastating Impact of Wrong-Site Surgery

WSS isn’t just a procedural error. It can have life-altering repercussions for patients. This is evident in an incident reported by KSDK, which illustrates the physical and emotional trauma experienced by Natalie Avilez from St. Louis. 

Avilez sought a routine disc herniation surgery to address back pain, only to have the surgeon operate on the wrong side of her spine. This mistake necessitated a second surgery, but even worse, she claims the surgeon operated on the wrong level entirely, removing unnecessary bone.

This is a horrifying example of how wrong-site surgery can lead to additional, often more complex surgeries, extending recovery times significantly. In some cases, permanent disability can result, leaving patients with chronic pain or limitations in movement. The most tragic consequence is the potential for death due to complications or additional procedures.

Beyond the physical suffering, WSS inflicts a deep emotional toll. Patients grapple with feelings of betrayal, anger, and a loss of trust in the medical system. Family members also share the burden of worry and fear, creating a ripple effect of emotional distress.

Why “Never Events” Like Wrong-Site Surgery Persist

Despite being classified as preventable, WSS continues to occur due to a combination of human and systemic factors. Here’s a closer look at the main culprits:

• Communication breakdowns: A lack of clear communication between surgeons and other healthcare providers can lead to misunderstandings about the planned procedure and surgical site.
  
• Misidentification of the surgical site: Improper marking of the surgical site can create confusion and lead to operating on the unintended area.
  
• Confusion about laterality: Mistakes involving left versus right body parts, especially during procedures on paired organs or limbs, can have devastating consequences.
  
• Non-adherence to safety protocols: Failure to follow established safety measures, which includes “time-out” procedures for verification before surgery, creates a gap in safeguards designed to catch errors.
  

The American College of Surgeons’ study underscores a crucial point: most healthcare institutions have the necessary safety measures in place. The challenge lies in ensuring their proper implementation and eliminating distractions or shortcuts during the surgical process. 

Their analysis of malpractice claims revealed that while some argue for stronger policies, the bigger issue lies in implementation. The top contributing factor was the failure to follow policy/protocol, though only 14.7% of claims were related to a need for new policies. 

This suggests that the main issue is not in creating policies but in ensuring their proper implementation. Researchers concluded that healthcare teams must perform these checklists more diligently, without distraction or shortcuts, to effectively prevent errors. 

Efforts to Prevent Wrong-Site Surgery

The Joint Commission’s National Patient Safety Goals outline several key strategies to eliminate WSS.

First, using a minimum of two patient identifiers to confirm patient identity is essential. This practice ensures that the correct patient receives the intended procedure. Identifying and reducing risks to patient safety is another fundamental step. Healthcare providers must be vigilant in recognizing and mitigating potential hazards throughout the surgical process.

Specific measures to prevent surgical mistakes include marking the correct surgical site on the patient. Verifying the correct surgery is performed on the correct patient is another crucial step. Additionally, taking a brief pause before starting surgery to ensure no errors have been made is essential in preventing surgical mistakes.

This “time-out” procedure allows the surgical team to double-check all details. Providing patients with written instructions on their medications helps ensure they understand their treatment and reduce the risk of medication errors.

By rigorously implementing these strategies, healthcare providers can significantly reduce the incidence of wrong-site surgeries and improve overall patient safety.

Resources and Support For Patients

The aftermath of wrong-site surgery can be overwhelming. Fortunately, resources are available to help patients navigate this difficult journey.

Legal Support 

Medical malpractice can be complex, and seeking legal counsel is crucial. Medical malpractice legal experts, like St. Louis personal injury lawyers in the case of Natalie Avilez, can help patients understand their rights and legal options.  

TorHoerman Law notes that these lawyers specialize in cases involving medical errors. They can guide patients through the legal process of seeking compensation for their physical, emotional, and financial losses.

Moreover, personal injury lawyers can coordinate with medical experts to provide testimonies that bolster the patient’s case. They can also connect patients with financial advisors and other professionals to manage the financial impact of medical errors.

Support Groups

Support groups provide a safe space to share experiences, find emotional support, and learn from each other. Connecting with others who have experienced similar situations can be incredibly helpful. Organizations like The National Patient Safety Foundation or The Leapfrog Group can connect patients with relevant support groups in their area.

Additional Resources

Government agencies like the Food and Drug Administration (FDA) or The Joint Commission offer resources and information on how to report medical errors. These resources can empower patients to advocate for themselves and promote safer healthcare practices.

Frequently Asked Questions

What happens in a never event?

In a never event, a serious incident occurs that is wholly preventable because safety recommendations provide strong systemic protective barriers. These incidents highlight failures in following established safety protocols, as these protections should have been implemented by all healthcare providers.

What is surgical failure?

Surgical failure refers to an outcome in surgery that does not meet the intended goals or expectations. It encompasses a range of issues from technical errors and complications to failure in achieving the desired medical outcomes. Surgical failure can result from various factors, including human error, equipment malfunction, or unforeseen complications.

What were the primary issues in surgery?

The main problems in surgery historically included infection, pain management, and bleeding control. Infections were often fatal before the discovery of antibiotics. Pain management was challenging without effective anesthesia. Bleeding control required advancements in surgical techniques and tools to minimize blood loss during procedures.

Wrong-site surgery isn’t just a medical error. It’s a stark reminder of the importance of constant vigilance in healthcare. While the human cost of such “never events” is undeniable, significant efforts are underway to prevent them. 

Healthcare institutions have a responsibility to continuously refine safety measures and ensure their proper execution. Patients, armed with knowledge and resources, can actively participate in their care and voice any concerns. Legal recourse can hold negligent parties accountable and deter future errors.

By working together, healthcare providers, patients, and legal systems can create a healthcare landscape where “never events” truly become a thing of the past. This collective effort promotes a culture of safety, protecting patients from the devastating consequences of WSS.