The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 1

The Orthopaedic Forum | January 04, 2012

The Occurrence of Wrong-Site Surgery Self-Reported by Candidates for Certification by the American Board of Orthopaedic Surgery

Michelle A. James, MD¹; John Gray Seiler, III, MD²; John J. Harrast, MS³; Sanford E. Emery, MD, MBA⁴; Shepard Hurwitz, MD³

¹ Shriners Hospitals for Children, Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817. E-mail address: mjames@shrinenet.org
² Georgia Hand, Shoulder, and Elbow, 1819 Peachtree Street, Suite 425, Atlanta, GA 30309
³ American Board of Orthopaedic Surgery, 400 Silver Cedar Court, Suite 100, Chapel Hill, NC 27514
⁴ Department of Orthopaedics, West Virginia University, Box 9196, 1 Medical Center Drive, Morgantown, WV 26506

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J Bone Joint Surg Am, 2012 Jan 04;94(1):e2 1-12. doi: 10.2106/JBJS.K.00524

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Abstract

Background:

The concept of “Sign Your Site” was established in 1997 to prevent wrong-site surgery in the U.S., and this was expanded to the mandated Universal Protocol in 2008. However, the true incidence of wrong-site surgery in the U.S. is not known, nor do we know whether the incidence has changed. The American Board of Orthopaedic Surgery (ABOS) requires that candidates for Board certification provide a list of their cases, including surgical complications, whether wrong-site surgery was performed, and whether they complied with the “Sign Your Site” practice. Each candidate attests to the accuracy of his or her notarized case list. The purpose of this study was to report the incidence and nature of wrong-site surgery self-reported by orthopaedic surgeon candidates for certification between 1999 and 2010 and to assess whether any change was associated with the timeline of implementation of the Universal Protocol.

Methods:

The ABOS database was queried for the number of examinees, cases, and wrong-site surgery cases reported; a description of each wrong-site surgery case; whether the site was signed; and the surgeon's subspecialty.

Results:

From 1999 through 2010, 9255 orthopaedic surgeons submitted 1,291,396 cases, and sixty-one of these surgeons reported performing seventy-six wrong-site surgical procedures. Spine surgeons were the most likely to report wrong-site surgery, most commonly single-level lumbar laminotomy. The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate was not significantly different. Eighteen of the twenty wrong-site surgical procedures performed since ABOS data collection for “Sign Your Site” began had been signed preoperatively.

Conclusions:

Keeping patients safe remains an essential goal worthy of enormous effort. This study suggests that additional layers of precautions may yield diminishing returns and that attention should be focused on methods to prevent wrong-level spine surgery. Improving communication among the health-care team and shared responsibility may bring us closer to eliminating wrong-site surgery.

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Introduction

Introduction | Materials and Methods | Results | Discussion | Appendix

The performance of surgery is a complex human enterprise that requires the interaction of multiple systems. Like all complex interactions, it can be complicated by error¹. Orthopaedic surgeons, who routinely operate on diseased limbs, digits, or spine segments that may not appear different from adjacent or contralateral parts, are at risk of making the error of operating on the wrong body part, wrong side, or wrong level.

In 1995, public reporting of a wrong-side amputation heightened awareness of this issue and instigated a public call for implementation of safeguards in hospitals^2,3. In an effort to advance the public good, the American Academy of Orthopaedic Surgeons (AAOS) established and began promoting the concept of “Sign Your Site” in 1997^4,5, and the North American Spine Society followed in 2001 with guidelines for signing, marking, and obtaining a radiograph of the appropriate spine segment⁶.

These efforts have been expanded and adopted by regulatory agencies. The eradication of wrong-site surgery has been considered a reachable goal by the AAOS^5,7 and The Joint Commission (TJC)⁸. In 2004-2005, TJC implemented the Universal Protocol, which includes preoperative verification of patient and site, surgical site marking, and a time-out before the procedure for repeat verification, and made this process mandatory for accreditation⁹. In spite of these efforts, TJC recently reported an increase in wrong-site surgery⁸ and responded by expanding preoperative procedures for identification of the patient side and the proposed operative site¹⁰ and by prioritizing implementation of the Universal Protocol by designating it as a National Patient Safety Goal¹¹.

Efforts to eliminate wrong-site surgery or to determine the efficacy of current systems to prevent such errors are hampered by the fact that the true incidence and impact of wrong-site surgery in the U.S. are not known. It is unclear whether the incidence has changed over the time during which these efforts have been under way. Although TJC assumes that the current estimate of eight to ten cases per month, which is based on mandated reporting since 2004-2005, represents an increase⁸, it is not known whether the increased reporting represents an increased incidence. Other evidence indicates that the rate may have decreased slightly¹² and that some cases go unreported in spite of reporting mandates^13,14. Other estimates of the incidence are based on biased populations. In 1998 an AAOS Task Force studied data from Physician Insurers of America that included 225 wrong-site surgery claims made against a pool of 110,000 orthopaedic surgeons (0.02% of orthopaedic surgeons per year)¹⁵. However, the data included only cases for which malpractice claims had been made, and not all wrong-site surgery results in malpractice claims^16-18. Surveys of hand surgeons¹⁶, surgeons who perform knee arthroscopy¹⁷, and spine surgeons¹⁸ have shown similar rates of wrong-site surgery among these three groups (Table I), and a recent survey of approximately 25% of AAOS members (one-sixth of whom responded) also indicated that this problem persists¹⁹. However, as in many survey studies, the response rate in the latter survey was low and respondent bias may have existed. Perhaps the most reliable information on the incidence of wrong-site surgery and the effect of preoperative site marking comes from Canada²⁰, where the “Operate Through Your Initials” campaign began in 1994 and where wrong-site surgery is closely tracked nationwide. Twelve cases of wrong-site surgery were reported in 1994 and one in 2000 (Table II), with most of the cases occurring in cases in which the site had not been marked²⁰.

The American Board of Orthopaedic Surgery (ABOS) requires that candidates for Board certification provide a notarized list of all cases performed during a specified six-month period of the year prior to their Part II Oral Examination. Since 1999, candidates for the Part II Oral Examination have been asked to report surgical complications, and specifically whether wrong-site surgery was performed; since 2007, they have been asked to report their compliance with “Sign Your Site” and the “time-out” before the skin incision. ABOS diplomates applying for recertification via the Oral Examination pathway provided a six-month case list until 2007. Since 2007, ABOS diplomates have applied through a Maintenance of Certification (MOC) process instead of through recertification and have submitted a three-month case list if they chose one of the computer-based Written Examination pathways or a six-month case list if they chose the Oral Examination pathway; however, the case lists contained the same information about surgical complications, wrong-site surgery, and “Sign Your Site” compliance. Because surgeons are required to submit case lists to be certified, to be recertified, or to maintain certification, and because they must attest to the accuracy of the list, data from these case lists are likely to be more accurate than data from other methods of self-reporting.

The purposes of this study were (1) to report the incidence and nature of wrong-site surgery by orthopaedic surgeons applying for ABOS certification between 1999 and 2010, and (2) to assess whether implementation of the TJC Universal Protocol was temporally associated with a change in the incidence of wrong-site surgery.

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TABLE I Wrong-Site Surgery Survey Results According to Subspecialty

	Hand Surgeons*¹⁶	Knee Arthroscopists†¹⁷	Spine Surgeons‡¹⁸
No. of respondents	1050	1301	415
Response rate	67%	83%	12%
No. who reported ever having performed wrong-site surgery	217	108	207
Percentage who reported ever performing wrong-site surgery	21%	8.3%	50%
Percentage of estimated cases performed that were wrong-site surgery	0.03%	0.04%	0.03%
Percentage of wrong-site surgery cases that led to legal action	38%	50%	17%

*Members of the American Society for Surgery of the Hand.
†Members of the Arthroscopy Association of North America.
‡Members of the American Academy of Neurological Surgeons.

TABLE I Wrong-Site Surgery Survey Results According to Subspecialty

	Hand Surgeons*¹⁶	Knee Arthroscopists†¹⁷	Spine Surgeons‡¹⁸
No. of respondents	1050	1301	415
Response rate	67%	83%	12%
No. who reported ever having performed wrong-site surgery	217	108	207
Percentage who reported ever performing wrong-site surgery	21%	8.3%	50%
Percentage of estimated cases performed that were wrong-site surgery	0.03%	0.04%	0.03%
Percentage of wrong-site surgery cases that led to legal action	38%	50%	17%

*Members of the American Society for Surgery of the Hand.
†Members of the Arthroscopy Association of North America.
‡Members of the American Academy of Neurological Surgeons.

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TABLE II Wrong-Site Surgery Cases Reported to Canadian Malpractice Insurers According to Year*²⁰

Year	No.
1987	9
1988	13
1989	16
1990	9
1991	15
1992	10
1993	7
1994†	12
1995	4
1996	13
1997	8
1998	6
1999	7
2000	1

*819 orthopaedists were practicing in Canada in 2002.
†The “Operate Through Your Initials” campaign began in 1994.

TABLE II Wrong-Site Surgery Cases Reported to Canadian Malpractice Insurers According to Year*²⁰

Year	No.
1987	9
1988	13
1989	16
1990	9
1991	15
1992	10
1993	7
1994†	12
1995	4
1996	13
1997	8
1998	6
1999	7
2000	1

*819 orthopaedists were practicing in Canada in 2002.
†The “Operate Through Your Initials” campaign began in 1994.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Appendix

The ABOS database for 1999 though 2010 was queried for (1) the number of examinees seeking to be certified via the Part II Oral Examination, to be recertified via the Oral Examination pathway (before 2008), and to maintain certification via either the Written or the Oral Examination pathway (2008 through 2010); (2) the total number of cases reported; (3) the number of wrong-site surgical cases reported; (4) a description of the wrong-site surgery; (5) the Common Procedural Terminology (CPT) code for the wrong-site surgery; (6) whether the surgical site had been signed preoperatively (available for 2007 through 2010 only); and (7) the self-identified subspecialty of the surgeon who performed the wrong-site surgery. When detailed information about the circumstances of the wrong-site surgery and its outcome and impact on the patient was provided by the candidate, this information was reviewed and classified as (1) wrong-site local or regional anesthesia; (2) wrong-site skin incision; (3) wrong-site surgical exposure; (4) incomplete operation on the wrong site; (5) wrong procedure; (6) wrong side; (7) wrong digit; or (8) wrong level of the spine. When data were available, these cases were also classified according to whether the error was recognized and corrected during the same operative and anesthetic session (see Appendix).

To estimate the potential impact of an inclusion bias (if surgeons postponed taking the certification examination because they had performed a wrong-site surgery during the case collection period), the database was also queried to identify orthopaedic surgeons who submitted a case list but did not sit for the examination, and their cases were examined for the same information as described above.

Statistical Analysis

Statistical analysis was performed with use of SPSS (version 17.0 for Windows; SPSS, Chicago, Illinois). The chi-square test with Yates correction was used to compare the incidence of wrong-site surgery reported in the literature (Table I) with that reported by the ABOS Part II examination candidates (Table III). The Fisher exact test was used to compare the incidence of wrong-site surgery before and after implementation of the Universal Protocol mandate. A p value of <0.05 (two-sided) was considered significant.

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TABLE III Wrong-Site Surgery Cases Reported During the ABOS Part II Examination According to Self-Declared Subspecialty

	Hand Surgeons	General Orthopaedic and Sports Surgeons	Spine Surgeons
No. of surgeons	903	4923	897
No. who reported performing wrong-site surgery	6	27	31
Percentage who reported performing wrong-site surgery	0.66%	0.55%	3.01%
Percentage of cases performed that were wrong-site surgery	0.004%	0.005%	0.041%

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TABLE III Wrong-Site Surgery Cases Reported During the ABOS Part II Examination According to Self-Declared Subspecialty

	Hand Surgeons	General Orthopaedic and Sports Surgeons	Spine Surgeons
No. of surgeons	903	4923	897
No. who reported performing wrong-site surgery	6	27	31
Percentage who reported performing wrong-site surgery	0.66%	0.55%	3.01%
Percentage of cases performed that were wrong-site surgery	0.004%	0.005%	0.041%

Source of Funding

The American Board of Orthopaedic Surgery funded the statistical analysis of the data for this study. No external funding was received.

Results

Introduction | Materials and Methods | Results | Discussion | Appendix

ABOS case list data for self-designated hand surgeons, general orthopaedic surgeons or sports medicine specialists, and spine surgeons were examined for wrong-site hand, arthroscopic, and spine surgery. This information was compared with published studies involving self-reporting (Tables I and III). The ABOS information represented a six-month snapshot, whereas the published studies involved data collection periods of varying lengths; the most valid comparison would therefore involve the percentage of cases that were wrong-site surgery. Meinberg and Stern reported the rate of wrong-site surgery among hand surgeons to be 0.03%¹⁶, whereas a rate of 0.004% was calculated from the ABOS data (p < 0.0001). McDaniel and Albright reported the rate of wrong-site surgery among surgeons performing knee arthroscopy to be 0.04%¹⁷, whereas a rate of 0.005% was calculated from the ABOS data (p < 0.0001). Mody et al. reported the rate of wrong-site surgery among spine surgeons to be 0.03%¹⁸, whereas a rate of 0.041% was calculated from the ABOS data (p = 0.1285).

The incidence of wrong-site surgery before July 1, 2005, when TJC mandated the Universal Protocol, was compared with the incidence after this date. Surgical procedures on the case lists collected for the 1999 through 2005 examination years were performed before institution of the mandate, and surgical procedures on the case lists collected for the 2006 through 2010 examination years were performed after institution of the mandate. The 609,715 cases reported from 1999 through 2005 included forty-four wrong-site surgical procedures (0.0072%), and the 435,382 cases reported from 2006 through 2010 included twenty-seven wrong-site surgical procedures (0.0062%). This difference was not significant (p = 0.550; Fisher exact test, two-tailed). A similar analysis was also performed after surgical procedures involving the spine were excluded. The 568,438 non-spine cases reported from 1999 through 2005 included twenty-four wrong-site surgical procedures (0.0042%), and the 398,873 non-spine cases reported from 2006 through 2010 included eleven wrong-site surgical procedures (0.0028%). Although this difference was also not significant (p = 0.303), the rate of non-spine wrong-site surgery fell 35% after institution of the Universal Protocol mandate, suggesting a trend. There were six fewer non-spine wrong-site surgical procedures during the five-year period from 2006 through 2010 than there would have been if the non-spine wrong-site surgery rate had remained at the 1999 through 2005 level.

Sixty-six of the 8206 orthopaedic surgeons undergoing the Part II Board certification process during 1999 through 2010 reported performing seventy-one wrong-site surgical procedures in 1,045,097 cases, equivalent to a rate of 0.0068% per case (Tables IV and V). One candidate reported four wrong-site surgical procedures during a single examination year, one reported two wrong-site surgical procedures during a single examination year, and one reported a single wrong-site surgery during each of two examination years.

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TABLE IV Wrong-Site Surgery Cases Reported During the ABOS Part II Examination According to Year

Year	No. of Examinees	Total No. of Cases	No. of Wrong-Site Surgery Cases	Rate of Wrong-Site Surgery (%)
1999	693	77,320	7	0.0091
2000	709	90,266	8	0.0089
2001	725	93,510	8	0.0086
2002	707	92,307	7	0.0076
2003	615	78,498	1	0.0013
2004	698	88,007	4	0.0045
2005	697	89,807	9	0.0100
2006	656	88,683	7	0.0079
2007	662	86,588	7	0.0081
2008	669	89,096	5	0.0056
2009	695	89,342	3	0.0034
2010	680	81,673	5	0.0061
Total	8206	1,045,097	71	0.0068

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TABLE IV Wrong-Site Surgery Cases Reported During the ABOS Part II Examination According to Year

Year	No. of Examinees	Total No. of Cases	No. of Wrong-Site Surgery Cases	Rate of Wrong-Site Surgery (%)
1999	693	77,320	7	0.0091
2000	709	90,266	8	0.0089
2001	725	93,510	8	0.0086
2002	707	92,307	7	0.0076
2003	615	78,498	1	0.0013
2004	698	88,007	4	0.0045
2005	697	89,807	9	0.0100
2006	656	88,683	7	0.0079
2007	662	86,588	7	0.0081
2008	669	89,096	5	0.0056
2009	695	89,342	3	0.0034
2010	680	81,673	5	0.0061
Total	8206	1,045,097	71	0.0068

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TABLE V Wrong-Site Surgery Cases Reported During the ABOS Part II Examination According to Self-Declared Subspecialty and Year

	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010	Total
Spine		4	2	1	1	2	7	3	5	2	1	3	31
General orthopaedics	5	2	5	2		2	2	4	1		2	1	26
Hand and upper extremity	1			2						2		1	6
Foot and ankle		1	1	1					1				4
Trauma		1								1			2
Sports medicine				1									1
Pediatric orthopaedics	1												1
Total	7	8	8	7	1	4	9	7	7	5	3	5	71

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TABLE V Wrong-Site Surgery Cases Reported During the ABOS Part II Examination According to Self-Declared Subspecialty and Year

	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010	Total
Spine		4	2	1	1	2	7	3	5	2	1	3	31
General orthopaedics	5	2	5	2		2	2	4	1		2	1	26
Hand and upper extremity	1			2						2		1	6
Foot and ankle		1	1	1					1				4
Trauma		1								1			2
Sports medicine				1									1
Pediatric orthopaedics	1												1
Total	7	8	8	7	1	4	9	7	7	5	3	5	71

Five of the 2508 orthopaedic surgeons applying to be recertified or maintain their certification during 1999 through 2010 reported performing five wrong-site surgical procedures in 246,299 cases, equivalent to a rate of 0.0020% (Table VI). Two of these five surgeons identified themselves as spine surgeons, one as a general orthopaedist, one as a foot and ankle surgeon, and one as a trauma surgeon.

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TABLE VI Wrong-Site Surgery Cases Reported During the ABOS Recertification or Maintenance of Certification Process According to Year

Year*	No. of Examinees	No. of Cases	No. of Wrong-Site Surgery Cases	Rate of Wrong-Site Surgery (%)
1999	92	15,000†	0	0
2000	71	11,000†	0	0
2001	61	10,000†	0	0
2002	50	8000†	0	0
2003	55	8792	0	0
2004	47	7396	0	0
2005	73	10,810	1	0.0093
2006	85	13,050	0	0
2007	74	12,985	0	0
2008	200	19,093	0	0
2009	651	50,798	1	0.0020
2010	1049	79,375	3	0.0038
Total	2508	246,299†	5	0.0020

*1999-2007: Recertification candidates choosing the Oral Examination pathway submitted a six-month case list. 2008-2009: Maintenance of Certification began, with three-month case list submission by all candidates regardless of pathway (Oral or Written Examination).
†Since 2003, the data analyzed excluded cases submitted by candidates who withdrew from the recertification process after submitting a case list but before taking the examination. Because data from 1999-2002 included cases of a known number of candidates who submitted case lists but failed to sit for the examination, but the exact number of cases they submitted was not known, the number of cases submitted by surgeons who sat for the examination was estimated (the number known to have failed to take the examination was multiplied by the average number of cases, and this was subtracted from the case total).

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TABLE VI Wrong-Site Surgery Cases Reported During the ABOS Recertification or Maintenance of Certification Process According to Year

Year*	No. of Examinees	No. of Cases	No. of Wrong-Site Surgery Cases	Rate of Wrong-Site Surgery (%)
1999	92	15,000†	0	0
2000	71	11,000†	0	0
2001	61	10,000†	0	0
2002	50	8000†	0	0
2003	55	8792	0	0
2004	47	7396	0	0
2005	73	10,810	1	0.0093
2006	85	13,050	0	0
2007	74	12,985	0	0
2008	200	19,093	0	0
2009	651	50,798	1	0.0020
2010	1049	79,375	3	0.0038
Total	2508	246,299†	5	0.0020

The wrong-site surgical procedures reported by the candidates who took the Part II Board Examination were also examined in more detail. Seventy-eight CPT codes were cited 149 times; of these, thirty-seven codes for spine procedures were cited ninety-four times (Table VII).

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TABLE VII Common Procedural Terminology (CPT) Codes for the Wrong-Site Surgery Cases Reported During the ABOS Part II Examination (1999-2010)

CPT Code	No. of Wrong-Site Surgery Cases	No. of Cases	Rate of Wrong-Site Surgery (%)	Description of CPT Code
63030	14	13,794	0.101	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar
22554	7	9354	0.075	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
63075	5	7514	0.067	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
20936	4	3586	0.112	Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)
22585	4	3759	0.106	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
22612	4	12,590	0.032	Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)
22842	4	7385	0.054	Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
26055	4	15,214	0.026	Tendon sheath incision (eg, for trigger finger)
29881	4	81,306	0.005	Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving)
69990	4	4928	0.081	Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)
22845	3	7746	0.039	Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
22851	3	6443	0.047	Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)
26160	3	6318	0.047	Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger
63035	3	1593	0.188	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)
63047	3	13,817	0.022	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
63076	3	2185	0.137	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)
20930	2	1751	0.114	Allograft for spine surgery only; morselized (List separately in addition to code for primary procedure)
20931	2	3328	0.060	Allograft for spine surgery only; structural (List separately in addition to code for primary procedure)
20937	2	6961	0.029	Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
22600	2	1441	0.139	Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
22614	2	4803	0.042	Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)
22630	2	4318	0.046	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
22802	2	848	0.236	Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments
22840	2	5408	0.037	Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
27236	2	26,165	0.008	Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement
29125	2	704	0.284	Application of short arm splint (forearm to hand); static
29877	2	33,214	0.006	Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
63045	2	696	0.287	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical
63048	2	6786	0.029	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)
63056	2	456	0.439	Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)
64483	2	3684	0.054	Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
11010	1	4653	0.021	Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues
11043	1	7945	0.013	Debridement; skin, subcutaneous tissue, and muscle
20650	1	1005	0.100	Insertion of wire or pin with application of skeletal traction, including removal (separate procedure)
20680	1	39,671	0.003	Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
20926	1	296	0.338	Tissue grafts, other (eg, paratenon, fat, dermis)
20938	1	2342	0.043	Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
22610	1	926	0.108	Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique)
22844	1	566	0.177	Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)
22846	1	716	0.140	Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)
22852	1	1057	0.095	Removal of posterior segmental instrumentation
24149	1	510	0.196	Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure)
24350	1	1015	0.099	Fasciotomy, lateral or medial (eg, tennis elbow or epicondylitis);
25111	1	10,101	0.010	Excision of ganglion, wrist (dorsal or volar); primary
26432	1	310	0.323	Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger)
26433	1	577	0.173	Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger)
26540	1	2271	0.044	Repair of collateral ligament, metacarpophalangeal or interphalangeal joint
26746	1	3040	0.033	Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each
26860	1	1498	0.067	Arthrodesis, interphalangeal joint, with or without internal fixation;
27228	1	1366	0.073	Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixation
27524	1	4845	0.021	Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair
27658	1	673	0.149	Repair, flexor tendon, leg; primary, without graft, each tendon
27766	1	4396	0.023	Open treatment of medial malleolus fracture, includes internal fixation, when performed
27826	1	684	0.146	Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula only
27828	1	2434	0.041	Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula
28080	1	1225	0.082	Excision, interdigital (Morton) neuroma, single, each
28110	1	296	0.338	Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)
28292	1	966	0.104	Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride, or Mayo type procedure
28306	1	697	0.143	Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal
28308	1	1002	0.100	Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each
28400	1	253	0.395	Closed treatment of calcaneal fracture; without manipulation
28415	1	2990	0.033	Open treatment of calcaneal fracture, includes internal fixation, when performed;
28730	1	646	0.155	Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse;
28820	1	1709	0.059	Amputation, toe; metatarsophalangeal joint
29085	1	16	6.250	Application, cast; hand and lower forearm (gauntlet)
29870	1	4805	0.021	Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)
29875	1	9219	0.011	Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)
29879	1	8137	0.012	Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture
29880	1	17,540	0.006	Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving)
61795	1	30	3.333	Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal (List separately in addition to code for primary procedure)
62290	1	715	0.140	Injection procedure for discography, each level; lumbar
62311	1	2626	0.038	Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)
63042	1	2821	0.035	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar
63046	1	298	0.336	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic
63081	1	1344	0.074	Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment
63267	1	168	0.595	Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
64721	1	42,554	0.002	Neuroplasty and/or transposition; median nerve at carpal tunnel
72295	1	335	0.299	Discography, lumbar, radiographic supervision and interpretation

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TABLE VII Common Procedural Terminology (CPT) Codes for the Wrong-Site Surgery Cases Reported During the ABOS Part II Examination (1999-2010)

CPT Code	No. of Wrong-Site Surgery Cases	No. of Cases	Rate of Wrong-Site Surgery (%)	Description of CPT Code
63030	14	13,794	0.101	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar
22554	7	9354	0.075	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
63075	5	7514	0.067	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
20936	4	3586	0.112	Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)
22585	4	3759	0.106	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
22612	4	12,590	0.032	Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)
22842	4	7385	0.054	Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
26055	4	15,214	0.026	Tendon sheath incision (eg, for trigger finger)
29881	4	81,306	0.005	Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving)
69990	4	4928	0.081	Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)
22845	3	7746	0.039	Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
22851	3	6443	0.047	Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)
26160	3	6318	0.047	Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger
63035	3	1593	0.188	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)
63047	3	13,817	0.022	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
63076	3	2185	0.137	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)
20930	2	1751	0.114	Allograft for spine surgery only; morselized (List separately in addition to code for primary procedure)
20931	2	3328	0.060	Allograft for spine surgery only; structural (List separately in addition to code for primary procedure)
20937	2	6961	0.029	Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
22600	2	1441	0.139	Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
22614	2	4803	0.042	Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)
22630	2	4318	0.046	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
22802	2	848	0.236	Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments
22840	2	5408	0.037	Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
27236	2	26,165	0.008	Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement
29125	2	704	0.284	Application of short arm splint (forearm to hand); static
29877	2	33,214	0.006	Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
63045	2	696	0.287	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical
63048	2	6786	0.029	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)
63056	2	456	0.439	Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)
64483	2	3684	0.054	Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
11010	1	4653	0.021	Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues
11043	1	7945	0.013	Debridement; skin, subcutaneous tissue, and muscle
20650	1	1005	0.100	Insertion of wire or pin with application of skeletal traction, including removal (separate procedure)
20680	1	39,671	0.003	Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
20926	1	296	0.338	Tissue grafts, other (eg, paratenon, fat, dermis)
20938	1	2342	0.043	Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
22610	1	926	0.108	Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique)
22844	1	566	0.177	Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)
22846	1	716	0.140	Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)
22852	1	1057	0.095	Removal of posterior segmental instrumentation
24149	1	510	0.196	Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure)
24350	1	1015	0.099	Fasciotomy, lateral or medial (eg, tennis elbow or epicondylitis);
25111	1	10,101	0.010	Excision of ganglion, wrist (dorsal or volar); primary
26432	1	310	0.323	Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger)
26433	1	577	0.173	Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger)
26540	1	2271	0.044	Repair of collateral ligament, metacarpophalangeal or interphalangeal joint
26746	1	3040	0.033	Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each
26860	1	1498	0.067	Arthrodesis, interphalangeal joint, with or without internal fixation;
27228	1	1366	0.073	Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixation
27524	1	4845	0.021	Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair
27658	1	673	0.149	Repair, flexor tendon, leg; primary, without graft, each tendon
27766	1	4396	0.023	Open treatment of medial malleolus fracture, includes internal fixation, when performed
27826	1	684	0.146	Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula only
27828	1	2434	0.041	Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula
28080	1	1225	0.082	Excision, interdigital (Morton) neuroma, single, each
28110	1	296	0.338	Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)
28292	1	966	0.104	Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride, or Mayo type procedure
28306	1	697	0.143	Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal
28308	1	1002	0.100	Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each
28400	1	253	0.395	Closed treatment of calcaneal fracture; without manipulation
28415	1	2990	0.033	Open treatment of calcaneal fracture, includes internal fixation, when performed;
28730	1	646	0.155	Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse;
28820	1	1709	0.059	Amputation, toe; metatarsophalangeal joint
29085	1	16	6.250	Application, cast; hand and lower forearm (gauntlet)
29870	1	4805	0.021	Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)
29875	1	9219	0.011	Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)
29879	1	8137	0.012	Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture
29880	1	17,540	0.006	Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving)
61795	1	30	3.333	Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal (List separately in addition to code for primary procedure)
62290	1	715	0.140	Injection procedure for discography, each level; lumbar
62311	1	2626	0.038	Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)
63042	1	2821	0.035	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar
63046	1	298	0.336	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic
63081	1	1344	0.074	Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment
63267	1	168	0.595	Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
64721	1	42,554	0.002	Neuroplasty and/or transposition; median nerve at carpal tunnel
72295	1	335	0.299	Discography, lumbar, radiographic supervision and interpretation

Candidates occasionally began but failed to complete the application process for the Part II Board Examination, or completed the application but failed to present themselves for the examination (Table VIII). No wrong-site surgical procedures were included in the case lists of the 203 candidates who failed to take the examination after submitting the case list. In 2003, the ABOS also began to track candidates who applied to take the examination but did not submit a notarized case list; eighty-seven candidates who applied between 2003 and 2010 failed to submit a notarized case list.

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TABLE VIII Number of Candidates Who Applied for But Did Not Sit for the ABOS Part II Examination According to Year

Year	No. of Candidates Who Submitted a Case List*	No. of Candidates Who Did Not Submit a Case List†
1999	6	Not recorded
2000	12	Not recorded
2001	16	Not recorded
2002	7	Not recorded
2003	8	0
2004	12	2
2005	16	5
2006	17	8
2007	17	12
2008	20	14
2009	20	13
2010	52	33
Total	203	87

*The candidates’ reasons for not sitting for the Part II Examination included denial (failed credentialing process), withdrawal, failure to attend the examination, failure to submit a complete application, and failure to submit a complete case list. No wrong-site surgical procedures were reported by these candidates.
†These candidates, whom the ABOS started tracking in 2003, applied to take the Part II Examination but failed to submit a notarized case list and did not sit for the examination. Therefore, this column represents the number of candidates who could have conceivably decided not to complete the Part II Examination application process because they performed a wrong-site surgery during the case collection period.

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TABLE VIII Number of Candidates Who Applied for But Did Not Sit for the ABOS Part II Examination According to Year

Year	No. of Candidates Who Submitted a Case List*	No. of Candidates Who Did Not Submit a Case List†
1999	6	Not recorded
2000	12	Not recorded
2001	16	Not recorded
2002	7	Not recorded
2003	8	0
2004	12	2
2005	16	5
2006	17	8
2007	17	12
2008	20	14
2009	20	13
2010	52	33
Total	203	87

Candidates were asked to describe the surgical complications that they reported in the case list. The description for each reported wrong-site surgical procedure was reviewed to (1) determine whether the error was recognized and corrected during the same anesthetic session, and (2) assess whether the wrong-site surgery would have had an impact on the outcome (see Appendix). Of the twenty wrong-site surgery cases reported by ABOS Part-II candidates in 2007 through 2010, the reports for eighteen indicated that the operative site had been signed by the surgeon preoperatively, and the reports for the remaining two (which were both wrong-level spine procedures) indicated that it had not been signed. The reports for two wrong-side surgery cases prior to 2007 noted that hospital policy for site signing had not been followed; one report indicated that the patient, surgeon, and staff had all identified and agreed on the wrong side preoperatively; and one report indicated that the patient had noticed that the wrong side was being prepared for surgery.

Sixty-one of the seventy-one wrong-site surgical procedures reported by Part-II candidates could be classified according to the type of wrong-site surgery (Table IX and Appendix). The remaining ten cases (six involving the spine, two involving the foot, and two for which the location was not specified) were reported by the candidate as a wrong-site surgery but the additional description either did not fit that designation or included no additional details to support the designation (Table X).

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TABLE IX Classification of Wrong-Site Surgery Reported by ABOS Part-II Candidates

Error	No. of Cases
Wrong-side local or regional anesthesia	2
Wrong-site skin incision	9
Wrong-site exposure	5
Incomplete operation(s)	2
Wrong procedure	7
Wrong side	7
Wrong digit(s)	3
Wrong level of spine	26
Total	61

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TABLE IX Classification of Wrong-Site Surgery Reported by ABOS Part-II Candidates

Error	No. of Cases
Wrong-side local or regional anesthesia	2
Wrong-site skin incision	9
Wrong-site exposure	5
Incomplete operation(s)	2
Wrong procedure	7
Wrong side	7
Wrong digit(s)	3
Wrong level of spine	26
Total	61

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TABLE X Complications Classified by ABOS Part-II Candidates as Wrong-Site Surgery with Information That Did Not Support this Designation or without Supporting Information

Case	Description of Operation	Description of Complication
1	Incision and drainage of foot for foreign body	Unable to locate foreign body
2	Excision of Morton's neuromas, 2nd & 3rd web spaces	Written consent obtained for 3rd web space neuroma excision only; verbal consent obtained for both by surgeon
3	Transforaminal epidural injection L1-L2	Unable to cannulate L5 neuroforamen secondary to degenerative changes and scoliosis. [Performed injection of] L1 neuroforamen secondary to previous posterolateral fusion L2-L5.
4	Transforaminal epidural injection left L4	Unable to [perform] midline injection secondary to unable to see landmarks so we did transforaminal injection.
5	Translaminar epidural injection	Dural puncture recognized and procedure aborted.
6	Provocative lumbar discography L3-L4 and L4-L5	Suboptimal needle placement for anular injection; required repeat injection 1 month later
7	T9-T11 laminectomy with posterior instrumented fusion using pedicle screws and iliac crest autograft.	Repeat myelogram showed persistent stenosis at adjacent cephalad level. Surgical plan appropriately followed but preoperative CT myelogram inadequate to identify adjacent level stenosis.
8	Lumbar decompression with laminectomy at one level and laminotomy and discectomy at 2nd level	Inadequate decompression; required revision decompression to fully decompress nerves
9	Removal of distal screws	No additional information provided
10	No procedure listed	No additional information provided

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TABLE X Complications Classified by ABOS Part-II Candidates as Wrong-Site Surgery with Information That Did Not Support this Designation or without Supporting Information

Case	Description of Operation	Description of Complication
1	Incision and drainage of foot for foreign body	Unable to locate foreign body
2	Excision of Morton's neuromas, 2nd & 3rd web spaces	Written consent obtained for 3rd web space neuroma excision only; verbal consent obtained for both by surgeon
3	Transforaminal epidural injection L1-L2	Unable to cannulate L5 neuroforamen secondary to degenerative changes and scoliosis. [Performed injection of] L1 neuroforamen secondary to previous posterolateral fusion L2-L5.
4	Transforaminal epidural injection left L4	Unable to [perform] midline injection secondary to unable to see landmarks so we did transforaminal injection.
5	Translaminar epidural injection	Dural puncture recognized and procedure aborted.
6	Provocative lumbar discography L3-L4 and L4-L5	Suboptimal needle placement for anular injection; required repeat injection 1 month later
7	T9-T11 laminectomy with posterior instrumented fusion using pedicle screws and iliac crest autograft.	Repeat myelogram showed persistent stenosis at adjacent cephalad level. Surgical plan appropriately followed but preoperative CT myelogram inadequate to identify adjacent level stenosis.
8	Lumbar decompression with laminectomy at one level and laminotomy and discectomy at 2nd level	Inadequate decompression; required revision decompression to fully decompress nerves
9	Removal of distal screws	No additional information provided
10	No procedure listed	No additional information provided

Discussion

Introduction | Materials and Methods | Results | Discussion | Appendix

Beginning more than a decade ago, professional organizations and regulatory agencies have been instituting new procedures to increase awareness of wrong-site surgery by the surgical team, with the goal of reducing the occurrence of this complication and eventually eliminating it entirely.

As an important part of its mission to protect the public, the ABOS requires that candidates submit for review a list of cases notarized by a local hospital official. The ABOS collection of wrong-site surgery data began in 1999, two years after the AAOS recommended the “Sign Your Site” procedure, and spanned the institution of the Universal Protocol and mandated reporting of wrong-site surgery by TJC in 2004-2005. Beginning in 2007, the ABOS added a requirement that candidates report compliance with the “Sign Your Site” mandate.

The present study did not measure a change in the incidence of wrong-site surgery temporally associated with institution of the “Sign Your Site” mandate, although a nonsignificant trend toward a reduced incidence was observed when procedures involving the spine were excluded from the analysis. Two of the twenty reports of wrong-site surgery occurring after 2007 indicated that the site had not been signed, but both were wrong-level spine fusions, for which intraoperative radiographic confirmation of the appropriate level is more important that site signing. The lack of a significant decrease in the incidence of wrong-site surgery after institution of the TJC mandate might be attributable to a beneficial effect of the AAOS “Sign your Site” recommendation prior to the TJC mandate.

Our study also did not support the existence of an increase in the incidence of wrong-site surgery that was recently noted in the TJC data⁸. It is possible that the increase in the TJC data reflects an increase in the percentage of wrong-site surgical procedures being reported since the institution of the reporting mandated, rather than an increase in the actual incidence. The response to this perceived increase, including expanded and redundant identification procedures, may not be indicated or effective.

The incidence of wrong-site surgery reported in the present study is very low, and none of the cases involved performance of surgery on the wrong patient. Most of the wrong-site surgical procedures reported were recognized and corrected at the time of the index surgery and were unlikely to have a lasting impact on the patient's musculoskeletal health. Ideally, however, wrong-site surgery should never occur. Most importantly, at least ten of the non-spine procedures and up to twenty-six of the wrong-level spine procedures may have caused permanent harm to the patient.

Wrong-level spine surgery deserves special emphasis. Surgical exposure of the wrong level probably has no significant clinical effects. Proceeding with a discectomy at an erroneous level will leave scar tissue. Wrong-level cervical or lumbar fusion may cause permanent harm by adversely impacting the biomechanics of the spine and also by delaying the correct surgery; for two patients, the delay in correct-level surgery may have allowed worsening of their neurological status.

The majority (fourteen) of the twenty-six wrong-level spine procedures involved the lumbar spine. Eight procedures involved the cervical spine. None of the reports indicated that neglecting to obtain intraoperative images was the cause of the wrong-level surgery, but eleven reports stated that intraoperative images had been misinterpreted; this was the most common reason given for wrong-level cervical and lumbar spine surgery. A readable localizer radiograph of the lumbar spine may be very difficult to obtain if the patient is morbidly obese. A second pitfall involved moving the retractors after the localizer radiograph had been obtained, without adequately marking the appropriate level. A third pitfall involved unrecognized movement of the tubular retractor during a minimally invasive procedure. Although failing to follow standard recommendations⁶ for identifying the correct level may have caused some of the errors, other errors may have occurred in spite of attempts to prevent wrong-level surgery. Renewed attention to this problem and innovative suggestions for identifying the correct spine level may help to reduce the occurrence of this most common type of wrong-site surgery.

This study has several strengths. Over a twelve-year period, 9255 candidates reported 1,291,396 surgical procedures in a standardized fashion. This reporting is more likely to be accurate than that in other surveys on wrong-site surgery because the ABOS requires submission of notarized lists of all surgical procedures performed during a standardized time period, explicitly asks for information on wrong-site surgery, may audit candidates’ reports for accuracy, and can impose penalties for the submission of inaccurate information.

This study also has weaknesses. First, although the rate of wrong-site surgery by spine surgeons was not significantly different from that reported by such surgeons in a survey¹⁸, the rates of wrong-site surgery by hand surgeons and by arthroscopy surgeons were both lower than those reported by such surgeons in two surveys^16,17. It seems unlikely that the surgeons surveyed would have over-reported their performance of wrong-site surgery, although it is possible that surgeons who have been in practice longer are more likely to have performed wrong-site surgery during their career than those whose cases are being scrutinized over a short period. Second, it is possible that some candidates who performed wrong-site surgery during their case collection period elected to postpone certification to avoid being examined regarding a wrong-site surgery, but no wrong-site surgical procedures were included in the case lists of the 203 candidates who postponed certification after submitting a case list. Third, it is possible that surgeons are more vigilant and therefore less likely to perform wrong-site surgery during their case collection period. However, most of the measures currently in place to prevent wrong-site surgery, such as “time-outs,” are dependent on the entire surgical team, not on the surgeon alone. Fourth, prior to 2007 candidates were not asked if they had signed the surgery site, so the assumption that they had been doing so throughout the study period may not be true, although the AAOS “Sign Your Site” campaign was widely publicized and most orthopaedic surgeons were likely to have been familiar with it by 1999. Finally, the true impact of the wrong-site surgery on the affected patients could not be determined from this study. The ABOS collects information on the occurrence of certain safety and quality measures as part of the certification process, but information regarding the physical and psychological impact of wrong-site surgery on the affected patients was not uniformly collected and therefore could not be analyzed.

A recent study of a large physician insurance database of self-reported medical errors also found persistent wrong-site surgery occurrences after the institution of the Universal Protocol²¹. Although complete elimination of wrong-site surgery is a laudable and critically important goal, it may not be achievable as long as surgery is performed by human beings. The rate of occurrence of this preventable complication appears to be low in orthopaedic surgery, the institution of the Universal Protocol and mandated reporting do not appear to have reduced the occurrence of this complication, and the incidence does not seem to be increasing. We do not know whether additional layers of precautions such as more detailed time-out procedures and checklists²² can eliminate wrong-site surgery. They probably improve patient safety in other ways—for example, by formally notifying the surgical team of patient allergies or the need for special equipment, or by reinforcing the significance of teamwork by reminding them to introduce themselves to each other. Certainly, cultural changes such as the sharing of responsibility for patient safety among all members of the health-care team and the empowerment of all members to share their concerns are advisable and valuable²². Enhancing communication among members of the surgical team may be the most worthwhile effort, as up to 100% of wrong-site surgical procedures have been reported to involve communication errors²¹. Finally, our findings indicate that more effective methods of discerning the correct spine level are needed.

Keeping patients safe throughout the continuum of care remains an essential goal worthy of enormous effort. This study suggests that imposing additional layers of precautions to prevent wrong-site surgery may yield diminishing returns at best, rather than achieving the elimination of this grave problem. Focusing patient safety efforts on improving health-care team communication and sharing of responsibility may bring us closer to achieving the critically important goal of eliminating wrong-site surgery.

Appendix

Introduction | Materials and Methods | Results | Discussion | Appendix

A table giving details of the wrong-site surgery cases in Table IX is available with the online version of this article as a data supplement at jbjs.org.

Harp JH. Human factors in medical errors. AAOS Bulletin. 2006;54:246.

Stein L. ‘Wrong-site’ surgical mistakes are rare, preventable. St. Petersburg, FL: St. Petersburg Times. 2010 Jun 21. http://www.tampabay.com/news/health/article1103803.ece. Accessed 2011 Jan 29.

Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Saf Health Care. 2002;11:57-63.

American Academy of Orthopaedic Surgery. Information statement: wrong site surgery. 2008 Dec. http://www.aaos.org/about/papers/advistmt/1015.asp. Accessed 2011 Jan 29.

American Academy of Orthopaedic Surgery. AAOS Bulletin October 1997. OK plan to end wrong-site surgeries. http://www2.aaos.org/aaos/archives/bulletin/oct97/wrong.htm. Accessed 2011 Jan 29.

Wong D; Mayer T; Watters W. Sign, mark and x-ray (SMaX): prevent wrong-site surgery. North American Spine Society, La Grange IL, 2001. http://www.spine.org/Pages/PracticePolicy/ClinicalCare/SMAX/Default.aspx. Accessed 2011 Jan 29.

Canale ST. Wrong-site surgery: a preventable complication. Clin Orthop Relat Res. 2005;433:26-9.

The Joint Commission. Total sentinel events reported by year; 2008. http://www.jointcommission.org/assets/1/18/se_stats_trends_year.pdf. Accessed 2011 Jan 29.

Carayon P; Schultz K; Hundt AS. Righting wrong site surgery. Jt Comm J Qual Saf. 2004;30:405-10.

Alander DH; Carmack DB. Joint Commission updates requirements for Universal Protocol. AAOS Now, December 2009. http://www.aaos.org/news/aaosnow/dec09/clinical8.asp. Accessed 2011 Jan 29.

The Joint Commission. National patient safety goals: universal protocol for preventing wrong site, wrong procedure, wrong person surgery. 2011. p 22. http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed 2011 Jan 29.

ECRI Institute. Quarterly update on preventing wrong site surgery project: digging deeper. Pennsylvania Patient Safety Advisory. 2010;7:26-31. https://www.ecri.org/Documents/PA_PSRS/2010.3_Advisory.pdf. Accessed 2011 Jan 29.

Clarke JR. How a system for reporting medical errors can and cannot improve patient safety. Am Surg. 2006;72:1088-91.

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Meinberg EG; Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003;85:193-7.

McDaniel WJ; Albright DA. The incidence of wrong-site surgery in knee arthroscopy. J Bone Joint Surg Br. 2005;87:347.

Mody MG; Nourbakhsh A; Stahl DL; Gibbs M; Alfawareh M; Garges KJ. The prevalence of wrong level surgery among spine surgeons. Spine (Phila Pa 1976). 2008;33:194-8.

Wong DA; Herndon JH; Canale ST; Brooks RL; Hunt TR; Epps HR; Fountain SS; Albanese SA; Johanson NA. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am. 2009;91:547-57.

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Stahel PF; Sabel AL; Victoroff MS; Varnell J; Lembitz A; Boyle DJ; Clarke TJ; Smith WR; Mehler PS. Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145:978-84.

Gawande A. The checklist manifesto: how to get things right. New York: Henry Holt; 2009. p 32-47.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. One or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

certification ; wrong-site surgery

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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Jonathan Kates, MF

Posted on February 02, 2012

The patient should sign the site

Bayhealth Medical Group

THIS IS WHY THE PATIENT SHOULD SIGN THE SITE (WHEN POSSIBLE) AND NOT THE SURGEON. Most people will not put their initials on the wrong side.

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Michelle A. James, John Gray Seiler, III, John J. Harrast, Sanford E. Emery, Shepard Hurwitz; The Occurrence of Wrong-Site Surgery Self-Reported by Candidates for Certification by the American Board of Orthopaedic Surgery. The Journal of Bone & Joint Surgery. 2012 Jan;94(1):e2 1-12.

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