(OAKBROOK TERRACE, Illinois, April 25, 2023) – Wrong-site surgeries (WSS) can cause serious medical and emotional harm, as well as significant financial and legal consequences for patients and healthcare providers. While the incidence of WSS is low, it caused 7.9% of sentinel events voluntarily reported to The Joint Commission from 2018 to 2021.

A new study in the May 2023 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS) analyzed closed claims data on WSS to identify risk factors, patterns and other circumstances of WSS. The claims were classified by allegations made by claimants, responsible services, types of procedures, injuries and contributing factors. Researchers performed a descriptive analysis of the variables and reviewed the clinical summary of each case.

The study reviewed 68 WSS closed claims cases from 2013 to 2020. Findings showed the services most frequently responsible for these cases were orthopedic (35.3%), neurosurgery (22.1%) and urology (8.8%). The most common types of procedures involving WSS were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%) and surgery on muscles/tendons, most commonly hand surgery (11.8%).

Additionally, the researchers found the severity of claims was higher in the inpatient setting compared to the ambulatory care setting. The most common alleged injuries included the need for additional surgery (45.6%), pain (33.8%), mobility dysfunction (10.3%), worsened injury (8.8%) and death (7.4%). The top contributing factors to WSS were failure to follow policy/protocol (83.8%) and failure to review medical records (41.4%).

“WSS is a preventable injury that can severely harm patients and is a critical topic that must be addressed in providing best patient care,” notes an accompanying editorial. “Despite efforts to reduce this sentinel event, WSS persists. Healthcare systems and practitioners should continue to study WSS events, look to implement new methods to prevent WSS and continue to work toward achieving the goal of making WSS a true never-event.”

Also featured in the May issue:

• Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications (Yale School of Medicine, New Haven, Connecticut)
• Improving Safety During Transitions of Care Through the Use of Electronic Referral Loops to Receive and Reconcile Health Information (East Carolina University Health, Greenville, North Carolina)
• Integrating Implementation Science in a Quality and Patient Safety Improvement Learning Collaborative: Essential Ingredients and Impact (Sinai Health, Toronto)
• Extending Maternal Care After Pregnancy: An Initiative to Address Health Care Disparities and Enhance Access to Care After Delivery (Parkland Health, Dallas)
• Creating a Stronger Culture of Safety Within US Community Pharmacies (commentary)
• A Description of the Variation in Quality and Patient Safety Structures Within a Health System (research letter)

For more information, please visit the JQPS website.

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Note for editors    
The article is “A Contemporary Analysis of Closed Claims Related to Wrong-Site Surgery,” by Joy Tan, MD; Jacqueline M. Ross, RN, PhD; Daniel Wright, BSN, RN, JD; Marc Philip Tanedo Pimentel, MD, MPH; and Richard D. Urman, MD, MBA. The article appears in The Joint Commission Journal on Quality and Patient Safety, volume 49, number 5 (May 2023), published by Elsevier.    

The Joint Commission Journal on Quality and Patient Safety    
The Joint Commission Journal on Quality and Patient Safety (JQPS) is a peer-reviewed journal providing healthcare professionals with innovative thinking, strategies and practices in improving quality and safety in healthcare. JQPS is the official journal of The Joint Commission and Joint Commission Resources, Inc. Original case studies, program or project reports, reports of new methodologies or the new application of methodologies, research studies, and commentaries on issues and practices are all considered.