Recently, The American Academy of Orthopaedic Surgeons appointed the Task Force on Wrong-Site Surgery to determine the prevalence of this type of error in orthopaedic patients. The Task Force was also charged with developing a recommendation regarding methods to prevent wrong-site surgery.
The Task Force obtained data on 110,000 physicians from the records of the Physician Insurers Association of America. These data showed that a total of 331 claims involving wrong-site surgery were submitted in all surgical disciplines from January 1, 1985, through December 31, 1995. Two hundred and twenty-five of these claims were related to orthopaedic procedures.
The Task Force also obtained detailed information about thirty-seven claims for either a loss payment or an expense payment, from 1977 to mid-1997, from the State Volunteer Mutual Insurance Company in Tennessee. Thirty-six of the claims involved procedures performed in a hospital, and one involved a procedure performed in an outpatient surgical center. The most common anatomical site was the knee (fifteen claims), followed by the foot and ankle (nine claims), the hip (five claims), the leg (three claims), the hand and fingers (three claims), and the wrist (two claims). The most common procedure was arthroscopy (fifteen claims), followed by a reconstructive procedure on the foot (seven claims), management of a fracture about the hip or a slipped capital femoral epiphysis (five claims), reconstruction about the hand or wrist (five claims), management of a fracture at a site other than the hip (three claims), removal of hardware (one claim), and osteotomy (one claim). Twenty-two of the claims involved an error discovered during the procedure, and fifteen involved an error discovered after it. After discovery of the error, the planned operation was carried out immediately in twenty patients, was delayed or postponed in nine, and was canceled or was performed by another surgeon in eight.
Orthopaedic surgeons are aware of the possibility of wrong-site surgery, and many have developed specific methods to avoid it. For example, a small notebook, carried whenever the surgeon sees patients, may be used to enter the patient's name, the operative procedure, the record number, and the site and side of the procedure each time a patient is scheduled for an operation. This book should be taken to the operating room and checked before the surgeon operates on a patient. At the time of admission, the physician should document, in the medical record, the procedure, the side to be operated on, and the information provided to the patient. The signed informed-consent form should be checked, again, immediately before the operation. While these methods serve as safeguards, none are foolproof.
The Task Force recommends what it believes to be a more appropriate method to eliminate wrong-site surgery. The Task Force suggests that, before the procedure, the surgeon should check the patient's chart and radiographs, have the patient identify the correct site and side to be operated on, and then mark the site with his or her initials. The initials should not be draped out of the operative field, and the surgeon should not make an incision unless his or her initials are visible. The Task Force does not think that making such a mark would alter the infection rate.
The Task Force believes that such limb identification is simple, reproducible, non-intimidating to the patient, and easily seen by the operating-room staff and the surgeon. The Board of Directors of The American Academy of Orthopaedic Surgeons approved the report of the Task Force on Wrong-Site Surgery in September 1997. The Academy believes that the universal use of this method will eliminate wrong-site surgery in orthopaedic patients and recommends it for all orthopaedic procedures.
Henry R. Cowell, M.D., Ph.D.