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  4.  » What are the causes of wrong-site surgery?

What are the causes of wrong-site surgery?

If you or a member of your family expect to undergo a surgical procedure, you should know about the causes that can lead to wrong-site surgery. The unexpectedness of wrong-site surgery and its potential to cause serious physical and psychological injury or death prompted the Joint Commission to identify it as a sentinel event in the late 1990s.

Between Jan. 1st, 2010 and Dec. 31st, 2013, the Joint Commission received 463 voluntary reports of surgical errors involving the wrong site, wrong procedure, wrong patient or wrong side. The estimated incidence across the United States, including Louisiana, is higher. As many as 50 incidents may occur per week. 

Correcting the problem involves identifying why it occurs. According to Hospitals in Pursuit of Excellence, eight hospitals and surgical centers around the country participated in the project the Joint Commission took on in 2014 to identify and reduce the risks of wrong-site surgery. It categorized root causes of wrong-site surgery according to the point in the process at which they occurred.

Pre-op and holding

Root causes that occurred during the preoperative phase of the procedure involved inadequate verification of patient information. It also involved inconsistent use of the site-marking protocol. The standard is for the surgeon to mark your body at the surgical site. Problems arose when surgeons did so using surgical-site markers that lacked approval for the purpose. 

Operating room

Wrong-site surgery can occur when communication is ineffective within the operating room. Defects during the preoperative time-out, including rushing, distractions or lack of full participation, can also lead to wrong-site surgery. 

Mistakes that can lead to wrong-site surgery can also occur during the scheduling process or due to the organizational culture. 

The information in this article is not intended as legal advice but provided for educational purposes only.

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