Wrong Site Surgery — A Common, but Preventable, Medical Mistake

When a Texas man underwent spinal surgery, he was shocked to discover that his doctor mistakenly removed the wrong thoracic spinal disk. The surgeon blamed an unclear MRI image and the patient's height - he measured 6 feet 2 inches - for making it more challenging to correctly count the vertebrae.

Although a subsequent surgery removed the correct herniated disk from the patient's spine, the damage caused by the surgeon's error could not be undone. The patient hired a medical malpractice law firm and successfully sued the spine surgeon.

Prevalence of Wrong Site Surgeries in New York

Sadly, the patient's experience is not as unusual as one would think. Operating on the wrong level of the spine is one of the most common mistakes that results in medical negligence lawsuits for wrong site surgery. While botched spinal surgeries account for a large proportion of medical malpractice suits, there are a plethora of other serious wrong site surgeries that often plague patients on the operating table.

The Joint Commission, a respected not-for-profit health care accreditation organization, defines wrong site surgery broadly as any surgery performed on the wrong body part or patient or the performance of the wrong procedure. The most common type of wrong site surgery as reported in a study published in the Annals of Surgery medical journal examining more than 430,000 operations, is wrong side surgery (for instance, incorrectly operating on the left arm instead of the right). The authors of the Annals of Surgery study estimate that a typical 300-bed hospital is likely to have one wrong site surgery event every year. By some estimates, 40 wrong site surgeries occur every week in the U.S.

Preventing Wrong Site Surgeries in New York

Wrong site surgeries can drastically alter the lives of victims. For instance, in one of the most egregious wrong site surgeries in recent memory, surgeons amputated the wrong foot on a patient afflicted with severe gangrene. Wrong site surgeries can leave patients permanently disabled, suffering chronic pain or requiring ongoing medical intervention.

What causes wrong site surgeries? Most experts cite a lack of communication. Surgery is a team effort, and high patient volumes mean team members often have less time to effectively communicate with each other - and with patients. Experts agree, wrong site surgeries are preventable. According to the National Quality Forum, they are classified as "never events", meaning they should never happen under any circumstances.

Patients who take an active role in their treatment - asking questions and discussing specifically what will be done during an operation with their surgeon - can help physicians avoid making wrong site surgical mistakes. The Joint Commission on Accreditation of Healthcare Organizations recommends that surgical patients go one step further by having their surgical site marked in the presence of their surgeon with a permanent marker, then asking the surgeon to initial the site.

Of course, while there are measures patients can insist on to help reduce the risk of wrong site surgery, ultimate responsibility to perform the right operation on the right body part lies with the surgical staff. Many health care institutions have instituted a policy for all operative and invasive procedures known as the Universal Protocol.

The Universal Protocol has three steps. First is pre-operative or pre-procedure verification. This step involves gathering and verifying all relevant records prior to the procedure. Identifying the patient with at least two identifiers (patient name, Medical Record number and date of birth) and verifying the correct procedure, including review of the signed consent form, are two of the most important tasks in the verification step. The second step is marking the operative or procedure site.

For procedures that involve a right/left distinction, multiple structures (like fingers and toes) or multiple levels (as is the case in spinal surgeries), the intended site should be clearly marked such that mark will be visible after the patient has been prepped and draped for surgery. If possible, the patient should be involved in the site marking process.

The final step of the Universal Protocol is a "time out" immediately before starting the procedure. This time out is a deliberate pause in activity that allows everyone in the operating room to actively listen and communicate any concerns. During the time out, final verification should be made as to patient identity, correct procedure, correct site and side verified with markings made previously, correct patient position, and the immediate availability of any special equipment required.

The Universal Protocol was established by the Joint Commission based on the consensus of clinical experts and is endorsed by the American Academy of Orthopaedic surgeons, among other professional health care groups. When performed together, the steps of the Universal Protocol are believed to have the potential to completely eliminate wrong site, wrong procedure, wrong person surgery. Yet, oversights by medical professionals mean that wrong site surgeries still occur with a troubling frequency. While all surgical procedures involve risks, having an operation performed at the wrong site does not have to be one of them.

If you or a loved one has been harmed by a wrong site surgery, get in touch with an experienced medical malpractice attorney as soon as possible - you may be entitled to compensation. In addition, by holding negligent doctors accountable for medical errors, you will be incentivizing a higher standard of care for all patients. Get the monetary recovery you deserve and set the bar high for surgeons by contacting a medical malpractice law firm today.

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