Published: 09/01/2007; Updated: 11/16/2007
Wrong-site surgery is perceived as a medical error that should never happen, not a medical risk that the patient must accept, and therefore a core patient safety problem. Legally, it qualifies under the principle of res ipsa loquitur. The National Quality Forum (NQF) includes wrong-site surgery events on its list of Serious Reportable Events, commonly referred to as never events. Several states use that list as the basis for reporting patient safety problems. In some states (eg, Minnesota), these reports are made public. Florida imposes fines and disciplinary actions against surgeons for doing wrong-site surgery. As of July 2006, they had disciplined 45 physicians; 3 had been fined $20,000 each.
The objective of this author is to identify factors contributing to this medical procedure failure or error. As embarrassing as it is the medical profession needs to address the problem while recognizing why it's occurring. Doing too much in too brief a period of time, being distracted, not reading the chart and allowing the system of health care to operate like factory piece work. Frankly it's not working for the doctors or the patients. Simply blaming doctors isn't the answer. We need to fix the system that allows it.
Objective: We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part).
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