Review Question - QID 216460

Operating on the right lower extremity instead of the left lower extremity constitutes wrong-site surgery, which is most commonly due to communication problems, including the lack of independent verification of the surgical site by more than one party.

Wrong-site surgery refers to a procedure that is performed on the wrong anatomical area or wrong laterality. This category of surgical mistakes also includes operating on the wrong patient or performing the wrong procedure. This is a "never" event: an adverse event that should never happen. Wrong-site surgery is most often due to communication errors, such as information not being communicated between operating staff, or team members not speaking up when necessary. These errors can be due to either misinformation or confusion, particularly with procedures involving symmetric structures. The Joint Commission has promulgated a Universal Protocol in an effort to reduce wrong-site, wrong-procedure, and wrong-patient surgeries. The three main stages of the Universal Protocol are conducting a pre-procedure verification process, marking the procedure site, and performing a time-out, which includes identifying the correct patient, correct surgical site, and correct procedure. The time-out involves the immediate team members, which allows for verification of the surgical site by more than one party.

Hempel et al. provide a systematic review discussing wrong-site surgery, retained surgical items, and surgical fires, all of which are considered "never" events in surgical safety. They discuss some of the policy issues that can contribute to wrong-site surgery, including protocols, forms that did not include enough detail, or poor standardization in the workflow or procedure. They additionally provide a review of studies looking at the intervention of instituting the Universal Protocol and the effect on near misses and events.

Incorrect Answers:
Answer 1: Draping by a chief resident instead of an intern is incorrect. While a chief resident may have more operative experience than an intern, the critical issue in this situation is communication. Independent verification of the procedure by multiple team members could have prevented the event prior to incision.

Answer 2: Exploration under regional anesthesia for real-time patient feedback can allow for a patient to additionally serve as a source of independent verification for the procedure. However, the critical mistake is not choosing general anesthesia over regional anesthesia, but rather a lack of communication. Independent verification of the patient, procedure, and surgical site should occur regardless of whether the patient is awake or under anesthesia.

Answer 4: Portable intraoperative radiography prior to incision to confirm the laterality is unnecessary. While intraoperative radiography may be useful during the case for surgical decision-making, the laterality of the foreign body is already known. Independent verification of the surgical site would have prevented the event.

Answer 5: Sterilization and draping of both lower extremities is unnecessary. Additionally, it would not necessarily prevent the event, but would only save the surgical team from resterilizing and redraping after the mistake has already been made. Independent verification of the surgical site would have prevented the event.

Bullet Summary:
Wrong-site surgery refers to surgery on the wrong site or for the wrong patient, and can be prevented with independent verification of the patient, the procedure, and the site.