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.