AHRQ Study Finds Wrong-site Surgery Rare and Preventable

Wrong-site surgery is extremely rare and major injury from it even rarer, according to a study supported by HHS' Agency for Healthcare Research and Quality. The study is being published in the April 2006 issue of Archives of Surgery. The term "wrong-site surgery" includes surgery on the wrong organ or limb, at the wrong site on the spine, or on the wrong person.

Researchers led by Mary R. Kwaan, M.D., M.P.H., Brigham and Women's Hospital and Harvard School of Public Health in Boston estimate that a wrong-site surgery serious enough to result in a report to insurance risk managers or in a lawsuit would occur approximately once every 5 to 10 years at a single large hospital.

The study assessed all wrong-site surgeries reported to a large medical malpractice insurer between 1985 and 2004 and found that the number of wrong-site surgeries conducted on limbs or organs other than the spine occurred once in every 112,994 operations. Forty cases of wrong-site surgery were identified among 1,153 malpractice claims and 259 instances of insurance loss related to surgical care. Twenty-five of the cases were non-spine wrong-site surgeries, with the remainder involving surgery of the spine.

The study found that simplicity and avoidance of excessive redundancy are the key features of successful site-verification protocols.