Eight hospitals around the U.S. joined together in a multi-year project to understand the risk factors that contribute to the problem of wrong site surgery that can result in claims of medical malpractice.

While wrong-site surgery is relatively rare, it's been estimated that as many as 40 surgical errors occur every week in the U.S. hospitals and outpatient surgery centers. Errors are more likely to occur when more than one surgical procedure is being done at a time. Surgical errors the project studied included not only wrong site surgery, but also wrong side surgery, wrong patient surgery and wrong surgical procedures.

The investigation into surgical errors found that there is usually not one cause of error but that a number of small errors occur that can affect how the medical team operates. The medical teams who participated in the project focused on finding and reducing weaknesses in the surgical process from the point of scheduling until the point of incision. They identified 29 main causes of wrong-site surgery as well as actions that can be taken to reduce the risks associated with each one. These causes included:

1. Surgical risks occurring during the scheduling phase: failing to confirm accuracy of surgical booking documents, accepting verbal requests for surgeries, failing to have all required forms at the time the surgery is scheduled, illegible or incomplete information on surgical booking forms

2. Surgical risks occurring during the pre-op period in the hospital: required medical documents are missing or incorrect; inadequate or rushed patient verification process; failing to mark the site of surgery in the pre-op holding area or inconsistent site marking or someone other than the surgeon making the surgical mark; using the wrong kind of marker or a sticker instead of a marker, inconsistent or absent time out process

3. Surgical risks occurring in the operating room: failing to verify site of surgery between each procedure being performed; failing to verify patient, procedure, site and side before beginning surgery; removing site markings or covering them; ineffective use of time out to ensure every member of team understands what is happening and that all concerns have been addressed

4. Culture of the medical center: staff are not empowered to speak, staff are not educated about policy changes, pressure to conduct more surgeries leads to shortcuts and rushing, lack of or inconsistent focus on patient safety

While surgical outcomes can never be guaranteed, surgical errors are avoidable. The medical organizations who participated in the Wrong-Site Surgery Project developed solutions that allowed them to significantly reduce the number of risk factors in each step of the process. Overall, the incidence of cases involving more than one problem decreased by 72 percent.

Source: The Joint Commission Center for Transforming Healthcare, "The Wrong Site Surgery Project."