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Wrong Site Surgery Still Occurs


The Joint Commission has been working to prevent Wrong Site Surgery (WSS) since 1998. They have come up with an initiative to prevent WSS using a checklist, the Universal Protocol, which contains several important changes in procedure:

  • Prior to every operation the physician examines the medical record with the patient and confirms every fact needed. This includes patient identification and surgery site location.
  • At this pre-op meeting, the surgeon will mark and initial the correct surgery site. This marking will be with an indelible ink pen, so there is no danger of infection or of the mark being erased during pre-op prep.
  • In the operating room and before any invasive activity has started, there will be a time out, led by the surgeon, where every team member reviews their role. This includes the surgeon touching the operative area near his or her initials and indicating to all team members verbally the correct site.

The list is more comprehensive, but these highlights indicate the preliminary methods used to prevent WSS. If it becomes apparent during surgery that the procedure is incorrect, the surgeon is guided to take immediate steps to correct the situation by doing the following:

  • Take appropriate steps to return the patient as nearly as possible to pre-operative condition.
  • Advise the patient as soon as practicable
  • If patient is under a general anesthesia, perform the desired procedure at the correct site unless there are medical reasons not to proceed
  • If patient is under local anesthesia, recommend to the patient what is the appropriate course of action to take
  • Truthfully answer any questions the patient has and then proceed as directed by the patient

The stated goal of the Joint Commission was to eliminate WSS and the use of these procedures has reduced WSS occurrences by 50% or more in measured institutions. However, it is estimated that WSS still occurs around 40 times a week.

Was I Given the Right Surgery?

If you or someone you know has been subjected to WSW you should review your case with an independent medical doctor, and seek an experienced medical malpractice lawyer’s advice on the situation.

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