50% of spine surgeons have performed a “wrong site” surgery
WRONG SITE SURGERY HIGHEST AMONG SPINE SURGEONS? (Orthopedics This Week)
Joseph Bosco, III, M.D. is vice chair of the Department of Orthopedic Surgery at The New York University Langone Hospital for Joint Diseases. Dr. Bosco, who is also director for the Center for Quality and Patient Safety, walks the halls with prevention in mind.
Dr. Bosco and his colleagues recently published an article on wrong-site surgery in The Journal of Bone and Joint Surgery. He told OTW, “We can’t assume that the problem has disappeared because we have instituted the Sign Your Site program. Our most recent data show that 21% of hand surgeons, 50% of spine surgeons, and 8.3% of knee surgeons have performed wrong-site surgery on at least one occasion.”
What? Really? How?
“There is more and more pressure to increase surgical volume and operate more efficiently,” says Dr. Bosco. “All you need is for the proverbial holes in the Swiss cheese to line up. If a physician schedules a left knee arthroscopy instead of a right knee arthroscopy, 99.99% of the time a nurse or other OR personnel will catch that. But the 0.01% does happen.”
“Problems can arise in spine cases, where there is often extensive deformity and abnormal pathology. You can get X-rays and show them to 10 spine surgeons; 5 will say the problem is at one level while the other 5 say it’s at another level.”
“On the joint replacement side, there was a case where the surgeon signed the patient’s right knee and the patient concurred that this was the correct knee. The physician assistant, however, prepped and draped the wrong knee; the surgeon thus operated on the wrong knee. The surgeon should have caught it…the nurses should have caught it. This is exactly why a preoperative time out is critical.”
Asked how he would proceed if he were to lead a commission to assess and rectify wrong-site surgery, Dr. Bosco stated, “We must ensure that the Universal Protocol is being utilized nationwide. Physicians and their teams must be thoroughly educated as to how to avoid such incidents; then we must verify that the protocol is being used. Videotaping procedures is an excellent way of determining compliance. Such checks are already done for police officers and airline pilots, so why not surgeons?”
“The entire team must stay in the moment, something that’s not so easy given the length of some procedures. But wrong-site surgery is everyone’s mistake. One person can make a mistake—but five cannot.”
Thomas A. Einhorn, M.D. is director of Clinical and Translational Research Development for the Department of Orthopaedic Surgery at The NYU Langone Hospital for Joint Diseases. “The numbers presented in this article are sobering. If this has not happened to you one might think, ‘How could someone make such a blunder?’ Frankly, it’s not so hard to see how it could happen. There was a hand surgeon in Boston who had a particularly full surgical caseload one day. He confused the incision on one of his carpal tunnel releases with that of a trigger finger case. The difference can be just a couple of centimeters; in a small patient it’s not a clear situation when you are not focused.”
“Efforts to correct this problem began with the Canadians, then the American Academy of Orthopaedic Surgeons instituted the Sign Your Site program. The Joint Commission has developed a Universal Protocol, but it is not used at every facility…and it is not being assessed for effectiveness. The publication of this recent JBJS Reviews article will hopefully drive the discussion and facilitate efforts to do more to address this problem.”