An Exploration of the Evidence on Preventing Wrong-Site Surgery

Abstract

Preventable medical errors are now the Centers for Disease Control and Prevention’s (CDC) third leading cause of death, which equates to 9.5% of all deaths in the United States, or nearly 700 deaths per day. One of these preventable medical errors is wrong-site surgery. Wrong-site surgery (WSS) is defined as “any surgical procedure performed on the wrong patient, wrong body part, wrong side of the body, or at the wrong level of the correctly identified anatomic site” (The American College of Obstetricians and Gynecologists, 2010, p. 786). The purpose of this project is to examine what measures have been implemented to prevent these errors from occurring and to examine what can be done to prevent these serious errors. This project is pertinent because errors in healthcare delivery pose a direct threat to patient safety and healthcare professionals need to fully understand standardized protocols, error causation, and be knowledgeable of ways to prevent these unsafe events. This project is a literature review on medical error studies and case studies of wrong-site surgeries. Several medical databases were used to search for peer-reviewed articles. Using root-cause analysis, the top causes of WSS were found to be communication failures, procedural compliance issues, and complications in leadership. Studies have demonstrated that “safety net” implementations have led to improved outcomes, as well as switching the focus to systems accountability rather than personal accountability when mistakes are made. Systems accountability, or just culture, is when events can be reported and errors can be examined, so conclusions can be reached and actions taken to be collectively understood. Medical errors can be prevented by following the universal protocol established for surgical procedures and by healthcare systems establishing a non-punitive environment in order to create a safety culture.