Jt Comm J Qual Patient Saf. 2023 Feb 11:S1553-7250(23)00053-3. doi: 10.1016/j.jcjq.2023.02.002. Online ahead of print.
BACKGROUND: Wrong-site surgeries are considered “never events” and continue to occur despite the implementation of the Universal Protocol by The Joint Commission in 2003.
METHODS: The authors reviewed closed claims data on wrong-site surgery between 2013 and 2020 from a medical malpractice company. The claims were classified by allegations made by claimants, the responsible services, the types of procedures, the injuries, and contributing factors. Researchers performed a descriptive analysis of the available variables and reviewed the clinical summary of each case.
RESULTS: Between 2013 and 2020, there were 68 wrong-site closed claims cases. The mean age of the patients was 55.7 (standard deviation 16.21) years, and 51.5% were female. The services most frequently responsible for these were Orthopedic (35.3%), Neurosurgery (22.1%), and Urology (8.8%). The most common types of procedures were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%), and surgery on muscles/tendons (11.8%). The severity of claims was higher in the inpatient setting compared to the ambulatory setting. The most common alleged injuries included the need for additional surgery (45.6%), pain (33.8%), mobility dysfunction (10.3%), worsened injury (8.8%), death (7.4%), and total loss (7.4%). The top contributing factors to wrong-site surgery were failure to follow policy/protocol (83.8%) and failure to review the medical records (41.2%). The mean closed claim value was $136,452.84, and 60.3% of cases were settled.
CONCLUSION: The risk of wrong-site surgeries is increased with spine surgeries, likely due to unique technical challenges. Further research is required to identify effective methods of prevention of these events.
PMID:36925434 | DOI:10.1016/j.jcjq.2023.02.002