When a surgeon performs a surgery on the wrong part of the body there is a wide range of health consequences that goes with it. Any delay in performing the correct procedure can unnecessarily prolong the injury, progress the injury or condition to a stage it should have gotten and also impact on the patient’s life expectancy. Generally, the patient will have to undergo a second procedure to correct the error.
If a patient contracts an injury either physically or psychological due to the negligence of a medical practitioner performing surgery on the wrong site they may be eligible for a legal remedy.
Causes of Wrong Site Surgery
The factors that contribute to medical errors resulting in wrong-site surgery have been:
- Actions or inactions of the surgeon
- Failing to clearly mark the area for surgery
- The position of the patient – they may be placed in a way that conceals the site marking for surgery.
- Inaccurate diagnosis, reports or images
- Wrong information passed on to other medical professional involved in the surgery
- Right hand vs left hand – it is suggested that because most people are right-handed and most equipment setups are right-handed people, a left-handed surgeon may be at a higher risk of making a surgical error.
- Time pressures can also play a part where an emergency surgery must be performed, for example, or the start time is delayed because of a previous surgery taking longer than expected.
- Medical history is not reviewed
- Lack of a formal check of the area for surgery
- Surgical mark added too early and the site mark washes away before the surgery or is removed too early during surgery preparation.
- Communication breakdowns
- Patient/family members incorrectly identify the site for surgery
- Between surgical team
- Incorrect information is shared with the surgical team
Risk of wrong site procedures increases in cases where:
- There is more than one surgeon present
- The patient is transferred from one surgeon to another
- Where multiple procedures are performed during one surgical sitting – especially when these procedures are on different sides of the body
- The patient physical characteristics are unique, for example, obese patients or patients with physical deformities may cause the surgeon to deviate from surgical norms and in these cases, the risk of wrong site surgery is increased
There is a universal protocol that is generally organised into the following three categories, if any of these aspects are left out of before the surgery commences the risk of wrong site surgery can increase:
In this phase, all relevant documents, studies, tests etc. are studied to ensure consistency with the patients expectations and to ensure that the surgical team understands the patient, their history, condition, the surgery and the surgical site.
Marking of the Surgical Site
The surgical site is marked so that the mark is visible to the surgical team after the patient is prepped for surgery. Site marking must also be marked by a physician, never on an non-operative site, marked for multiple incisions (where necessary).
This phase, referred to as ‘Time Out’, occurs just before the surgery happens and includes final verification that it is the correct patient procedure and that the surgery is to happen on the correct part of the patient’s body. Communication happens between all members and procedure is not started until all questions and concerns are raised and answered within the surgical team.