Scientific Article   |    
Patient Compliance in Avoiding Wrong-Site Surgery
Christopher W. DiGiovanni, MD; Lana Kang, MD; Jennifer Manuel, MD
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Investigation performed at the Department of Orthopaedics, Brown University School of Medicine, Providence, Rhode Island

Christopher W. DiGiovanni, MD
University Orthopedics, 1287 North Main Street, Providence, RI 02904. E-mail address: yodigi@aol.com

Lana Kang, MD
Jennifer Manuel, MD
Department of Orthopaedics, Brown University School of Medicine, 593 Eddy Street, Providence, RI 02903

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 May 01;85(5):815-819
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Background: Wrong-site orthopaedic surgery is an uncommon, devastating, and preventable complication. The sole responsibility for avoiding this inadvertent event has historically been placed on physicians, nurses, and ancillary health-care personnel. Very little attention has been focused on the role of the patient. The successful outcome of any surgical or medical intervention requires an interactive doctor-patient relationship. The hypothesis of this study was that a substantial number of patients who undergo elective orthopaedic surgery do not comply with instructions designed specifically to prevent wrong-site surgery.

Methods: We prospectively evaluated the frequency with which 100 consecutive patients in a private foot-and-ankle practice followed the explicit preoperative instruction, before they underwent elective orthopaedic surgery, to mark "NO" on the extremity that was not to be operated on. Full compliance was defined as a mark on the correct extremity consistent with the instructions. Partial compliance was defined as a mark that was different from that requested by the specific preoperative instructions, and noncompliance was defined as the absence of any mark. Specific demographic and surgical factors were recorded from medical charts and compared between compliant and noncompliant patients.

Results: Fifty-nine of the 100 patients marked the extremity correctly, thirty-seven made no mark, and four were considered partially compliant. Of the ten patients with a Workers' Compensation claim, seven were noncompliant compared with thirty (33%) of the ninety patients who had not made a Workers' Compensation claim (p = 0.023). Patients who had had a previous related surgical procedure also had a significantly higher rate of noncompliance (51%; nineteen of thirty-seven) compared with those with no previous surgery (29%; eighteen of sixty-three; p = 0.023).

Conclusions: A surprisingly high number of patients do not comply with explicit preoperative instructions created specifically to prevent wrong-site surgery. This behavior suggests that patients expect the system to "take care of everything," despite solicitation of their active participation to avoid such adverse events. Although physicians and related health-care personnel certainly have the greatest responsibility to provide the highest possible quality of care, patients undergoing surgery must be encouraged to take a more active role in their health care in order to optimize outcome and minimize risk.

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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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    Louise E. Moondancer
    Posted on July 29, 2010
    Conclusion Argumentative

    To the Editor:

    There are many factors involved in "noncompliance". Communication, lack of knowledge, language barriers, ineffective teaching and yes, uncooperative behavior. I do not think that it is helpful to promote the idea that patients are just dependent children who are being obstinate. When patients are told to do something that makes no sense to them they may well decide not to do it...instructions need to come with explanation and teaching. In risk management, we often see that informed consent is poorly administered with no documentation of teaching and a generic consent with a written in procedure. This is not to say that Physicians do not make an attempt to teach their patients but, as we all know, the most difficult thing about communication is actually accomplishing it.

    The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    Kirti M Marya
    Posted on August 08, 2003
    Re: Will literacy ratio affect the incidence of wrong site surgery?
    Department of Orthopaedic Surgery SSR Medical College, Belle Rive, Mauritius

    Dear Sir, The apprehension that high prevalance of illiterate population might have a positive bearing on the incidence of wrong site surgery, as mentioned by Sangwan et al is well founded in the third world. But this is not the real cause of the surgical mis-adventures, so to say! The real root of the problem lies in lack of communication. The time a resident doctor takes to explain to the patient what surgey is to be performed on the patient is the real cause of concern in the third world. Most of the consent work is only on paper, and the illiterate patient is never actually 'explained' the procedure as it is anticipated that he or she will, in any case, not be able to understand what has been explained! Even if this is so, it does not seem unreasonable to suggest to the patient that a wrong surgery might occur if the patient does not follow the instruction. No patient, surely, would not take that seriously enough not to follow what has been told. It is imperative that the communicaion is from the operating surgeon and is with meaningful strong comprehension. It is irrelevant whether the setting is of a developed or developing country. Patients are anyway keen to take initiative and responsibility for the relationship with the doctor. Surgeons worldwide are becoming more mechanical. They have created a long chain of intermediate staff members in between them and the patient. This adds to the chances of errors. I dont find it very hard for the surgeon to have a re-look at the patient prior to anaesthetization. The least we, as surgeons, can do for avoiding these errors, is to communicate with our patients directly and reminding them of the importance and consequencies of their compliance. Expecting a patient, already under mental stress of having to undergo the surgery, to show perfect compliance (pre-op drugs, physiotherapy, wound care, posture, weight-bearing, post-op medication etc) seems to be an unrealistic demand. Reference: 1. Andrew Ellner et al. Can patients get better at working with their doctors? BMJ 2003;327:303–4. 2. Christopher W. DiGiovanni, Lana Kang, and Jennifer Manuel. Patient Compliance in Avoiding Wrong-Site Surgery J Bone Joint Surg Am 2003; 85: 815-819.

    Sukhbir Singh Sangwan
    Posted on July 22, 2003
    Will literacy ratio affect the incidence of wrong site surgery?

    Sir, The authors deserve kudos for this study, but we believe that while the surgeon bears much responsiblilty, the patients are also responsible to some extent for wrong site surgery.In India the illiteracy rate is quite high. Wrong site surgery occurs despite the best efforts by the surgeons. There is no documentation of the exact incidence of wrong site surgery among Indians. The authors have rightly said that the patients are totally dependant on the surgeon for "taking care of everything". This article is an eye opener to this part of the world.

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