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									                                 CORRECT-SITE SURGERY

                               A publication of the Kentucky Medical Association Patient Safety Task Force

Wrong site surgery is a very rare occurrence in medicine, but it is a problem that can have devastating effects on a patient
and a provider. It is, however, a problem that can be prevented through simple planning and communication.

According to a study conducted by the Joint Commission on Accreditation of Healthcare Organizations, wrong-site surgery
was most common during orthopedic procedures, followed by urologic procedures and neurosurgical procedures. In another
study conducted by the State Volunteer Mutual Insurance Company, the most common procedure that resulted in wrong-site
surgery was arthroscopic knee procedures, followed by foot procedures. That same study showed that 46% of the cases
reported were caused by physician error, while 40% were caused by the incorrect site being prepared/draped by the hospital
staff. In the vast majority of the cases, the correct procedure was performed, but on the wrong side.

There are steps that can be taken to ensure correct-site surgery. The American Association of Orthopedic Surgeons issued
a report that recommends, “having the surgeon’s initials placed on the operative site using a permanent marking pen and
then operating through or adjacent to his or her initials.” The American Academy of Ophthalmology also issued a report that
suggests, “spelling out the operative eye (abbreviations are not acceptable) on the informed consent form, and matching the
operative eye against the doctor’s orders for pre-operative medication or dilation, the patient's ocular history, and
examination and patient response.” The Joint Commission on Accreditation of Healthcare Organizations suggests the
following strategies:


   Clearly mark the operative site and involve the patient              Develop a verification checklist that includes all
    in the marking process to enhance the reliability of the              documents referencing the intended operative
    process.                                                              procedure and site, including the medical record, X-
                                                                          rays, and other imaging studies and their reports, the
                                                                          informed consent document, the operating room
   Require an oral verification of the correct site in the
                                                                          record, and the anesthesia record; and direct
    operating room by each member of the surgical team.
                                                                          observation of the marked operative site on the
                                                                          patient.
   Personal involvement of the surgeon in obtaining
    informed consent.

   Ensure through ongoing monitoring that verification
    procedures are followed for high-risk procedures; and

To review the entire JCAHO “Sentinel Event” on wrong-site surgery, go to www.jcaho.org. To obtain a copy of the American
Association of Orthopedic Surgeons’ report on wrong-site surgery, go to their website at www.aaos.org.


These recommendations show that there should be involvement by everyone in the process, including the patient, and that
there should not be a total reliance on the surgeon to point out the correct site.

The Kentucky Medical Association Patient Safety Task Force appointed a Sub-Committee on Correct Site Surgery to
develop information that might be helpful to physicians and medical facilities. The sub-committee reviewed the various
reports and literature and looked at existing facility policies that have been implemented to ensure correct-site surgery. That
work culminated in a sample policy contained on the next page that can be used by medical facilities to help ensure correct-
site surgery. The sample policy is not a guideline nor does it establish a standard of care—it is information that may
be helpful to some institutions. Not all of the suggestions are adaptable to every institutional setting, but may be
used as appropriate to a given institution.

                                                                        Kentucky Medical Association Patient Safety Task
                                                                        Force
                                                                        Sub-Committee on Correct-Site Surgery
                                                                        4965 US HWY 42, Suite 2000
                                                                        Louisville, KY 40222

								
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