Wrong Site Surgery: Reasons and Implications

Wrong-site surgeries do not appear to have decreased since their description by the Joint Commission in 1998. Despite evidence-based data supporting the role of the Universal Protocol in reducing the risk of wrong-site surgeries, compliance amongst surgeons varies, with varying levels of compliance between specialties. Root cause analyses by the Joint Commission of a growing database of wrong-site surgeries more specifically identifies breakdowns in communication between surgical team members and the patient and family as the most common cause of wrong site surgery, followed by policy lapses such as not requiring the marking of surgical sites, failure to require operative site verification in the operating room and the performance of a verification checklist, incomplete patient pre-operative assessment, staffing issues, distraction factors, availability of pertinent information on the operating room, and organizational cultural issues. Effective reductions in wrong-site surgery appear to therefore call for a reassessment and possible modification of current interventional strategies; evolving conceptual frameworks in reducing wrong-site should account for the impact of current healthcare reform proposals on the culture of patient safety.