Wrong Site Surgery on the Rise

The above headline appeared in USA Today from the April 17, 2006, issue. The story by Robert Davis, starts off by noting that although there have been years of patient-safety efforts, "an increasing number of health care facilities have reported mistakenly removing the wrong limbs or organs, slicing into the wrong side of bodies and performing surgery on the wrong patients."

The original study on this reviewed 2.8 million operations over a 20-year period and was published in the April 2006 issue of Archives of Surgery. This study recorded all wrong-site surgery cases reported to a large malpractice insurance company between 1985 and 2004. This study uncovered 25 wrong-site operations that were identified.

The Joint Commission on Accreditation, a non-profit organization that sets patient safety requirements and guidelines, and inspects more than 15,000 hospitals and surgical centers nationwide received reports from health care facilities last year of 84 operations that involved the wrong body part or the wrong patient.

Dennis O'Leary, who heads the non-profit Joint Commission stated, "It's getting worse. I can assure you that this is just the tip of the iceberg," O'Leary says. "Some hospitals are reporting everything and some hospitals don't report anything at all."

Dr. Donald Palmisano, a New Orleans surgeon on the non-profit National Patient Safety Foundation's board of directors commented, "We're trying to get the number down to zero." He continues, "It is such a catastrophe when this happens."

The article reports that since 2004 the joint commission has required doctors to mark the spot they plan to cut while consulting with their patient before surgery. Additionally, the commission is encouraging patients to insist on such a mark prior to their surgery.

However, the article notes that many surgeons do not follow the guidelines. Dr. Glenn Rothman, chairman of surgery at Banner Desert Medical Center in Mesa, Arizona, commented, "They think this is useless. Doctors fight it because they are the captains of the ship. There is a lot of resistance to standardized conduct."