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Qual Saf Health Care 2008;17:396-400 doi:10.1136/qshc.2007.023564
  • Commentary

The egocentric surgeon or the roots of wrong side surgery

  1. John W Senders1,
  2. Regine Kanzki2
  1. 1
    University of Toronto, Toronto, Ontario, Canada
  2. 2
    University of Miami, Miami, Florida, USA
  1. John Senders, jwsenders{at}post.harvard.edu

    “Oh wad some power the giftie gie us

    To see the world as our patient sees it!

    It wad frae monie a blunder free us, And foolish notion.”

    (With apologies to R Burns)

    A wrong site procedure is an event in which any medical (frequently surgical) procedure is executed on the wrong body part, or on the correctly named body part but on the wrong side of a patient’s body. If the procedure is surgery then the event is a wrong site surgery or a wrong side surgery. Wrong side surgery is generally considered to be a subset of wrong site surgery. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) reviewed 15 reported cases of wrong side surgery in a “Sentinel Event Alert” of August 1988. The problem has gained more attention since that time. In 2003, JCAHO promulgated a “Universal protocol for eliminating wrong site, wrong procedure, wrong person surgery”. Our own interest arose (see Acknowledgement) from a chance event.

    There are no reliable probabilities of various kinds of wrong side and wrong site surgery, because of both poor numerators (number of events) and poor denominators (opportunities for events). JCAHO classifies wrong side surgery as “sentinel events” and accumulates statistics. From 2000 to 2005 there were 3044 sentinel events (categorised in table 1). Wrong site surgery events are near the top of the list and we may assume that about 80% of them were wrong side surgery events (see tables 2 and 3).

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    Table 1 Classification of 3044 sentinel events reviewed by JCAHO, January 1995 through March 20051
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    Table 2 Types of wrong surgery*
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    Table 3 Surgery error rates in the Veterans Administration system3

    As both JCAHO and the Veterans Administration (VA) system show, most wrong site surgery events are wrong side surgeries. The statistics offered are similar. JCAHO reports a wrong side/wrong site surgery ratio of 0.76 (0.59/(0.59+0.19)), and the VA ratio is 0.86 (0.44/(0.44+0.07)). Ericson4 of Washington University in St Louis estimates that …

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