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Wrong Site Surgery Blog
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Wrong Site Surgery

Few medical errors are as vivid and terrifying as those that involve patients who have undergone surgery on the wrong body part, underwent the incorrect procedure or had a procedure intended for another patient. These are medically and legally called "wrong-site, wrong-procedure, wrong-patient" mistakes (WSPEs) were labelled as preventable events, errors that should never occur and indicate serious underlying safety problems and is strictly punishable by law as it jeopardize one's life if a surgery is crucial, case by case. 

As years pass by, there is a proportional increase in wrong site surgery cases and claims in the US and because of this, Universal Protocol was created and agreed among medical providers. The Universal Protocol is a set of safety measures that all accredited hospitals, ambulatory care facilities and office-based surgery centers are required to follow. Prior to beginning any operation the health professionals involved in it must take time out from their work and discuss what they will be doing during this procedure with each other, it is an important practice known for improving teamwork among doctors as well as significantly reducing the risk of wrong site surgical procedures being conducted, the specific period aims to give space and mental and physical rest among those medical professional involved in the surgery. 

Even though this protocol has been around for quite some time, these mishaps still happen. In fact, 2,700 cases of this mistake occur each year where an incision was made in the incorrect spot or interchanging spots. Some surgeons and other medical staff are oftentimes confused maybe due to stress and pressure, as they tend to:

  • 59% of orthopedic surgeons tend to operate the wrong side of intended side.
  • 23% of them operate on the actual wrong site.
  • 14% almost or applied the wrong procedure
  • While the 5% literally operate with the wrong patient
  • These wrong site surgery are surprisingly occassional as it only occurs on every estimated 1 out of 112,000 surgery and to be only a patient experience one every 5-10 years. 

Main reason why wrong site procedures consistently occur is that communication issues is a prominent underlying factor. The concept of the surgical timeout was intented for medical professionals as a planned pause before beginning the procedure in order to review important aspects of the procedure with all involved personnel, this was developed based on this information after many instances where WSPEs were called into question and found to be due largely to lack or poor quality communcation among those present at surgery, including surgeons, medical assistants, nurses, anesthesiologists; even family members. In addition, checklists was even required for the medical professional to be checked and assessed thoroughly, it contains medical equipments needed, medical professionals needed and parts of which surgery will be conducted for a smooth sailing surgical procedure. 

Additional countermeasures to prevent wrong site surgery
  1. Create a checklist and communicate about it 
  2. Give one's self room to breathe and think 
  3. Involve everyone 
  4. Keep the surgical instruments in the room until completion of the time-out
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