April 26, 2023

Closed claims analysis identifies wrong-site surgery risks

Editor's Note

This study, published in The Joint Commission Journal on Quality and Patient Safety, analyzes 68 closed claims cases on wrong-site surgery from 2013 to 2020.

The services most frequently responsible for these cases were:

  • Orthopedics (35.3%)
  • Neurosurgery (22.1%)
  • Urology (8.8%).

The most common types of procedures involving wrong-site surgery were:

  • Spine and intervertebral disc surgery (22.1%)
  • Arthroscopy (14.7%)
  • Surgery on muscles/tendons, most commonly hand surgery (11.8%).

The most common injuries included:

  • The need for additional surgery (45.6%)
  • Pain (33.8%)
  • Mobility dysfunction (10.3%)
  • Worsened injury (8.8%)
  • Death (7.4%).

The top contributing factors to wrong-site surgery were:

  • Failure to follow policy/protocol (83.8%)
  • Failure to review medical records (41.4%).

The researchers also found that the severity of claims was higher in the inpatient setting, compared to the ambulatory care setting.


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