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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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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.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jan 04;94(1):e2 1-12. doi: 10.2106/JBJS.K.00524
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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.


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.


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.


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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    Accreditation Statement
    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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