A protocol for the reduction of surgical errors

• surgical errors
• wrong site/wrong side surgery
• patient involvement

Medical errors make headline news. The headlines will always emphasise the human suffering associated with medical error, but the prevention of such errors comes as the result of detailed analysis of their circumstances. One area of particular concern to surgeons is wrong site/wrong side surgery. Although its occurrence is rare, it is potentially avoidable. A notable recent case in the UK was that of a patient who died from renal failure after the removal of his healthy kidney and not his diseased one. Worldwide systems should be in place to prevent this occurring, but the data revealing the extent of the problem have not been readily available.

In the past there has been little opportunity to understand the cause of errors as such events—although rare—were often not reported and not collated with other similar events, preventing their repeated recurrence. Not surprisingly, doctors were often reluctant to disclose such errors or “near misses”. But attitudes and practices are changing. In the USA the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; www.jcaho.org; see box 1) has shown that, by the voluntary reporting of serious errors to a central body, these events can be analysed. This has revealed not only the relative rarity of wrong site/wrong side surgery, but has also allowed the pooling of data and their analysis, permitting guidelines to be drawn up to prevent their potential recurrence.