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Wrong-Site Surgery: Why It Occurs and How to Prevent It

Recently a study reviewed information from literature, patient interviews, and expert interviews on ways to prevent the too-common error of wrong-site surgery. Partly due to the high rate of skin cancers in the Medicare population, excisional surgery is one of the most common surgeries in medicine. Proper information must transfer from the biopsying physician to the operating surgeon in order for the correct site to be treated. In a survey of 150 dermatologists reporting medical errors, 19% noted wrong-site surgery as a “most serious error.” In an insurance company database, 107 of the 27,370 adverse events were wrong-site cases. The study gathered and reviewed factors that affect wrong-site surgeries and the methods used to prevent this mistake.

Anatomic and technical difficulties that lead to wrong-site surgeries include:

  • Other abundant lesions in the biopsy field
  • Other biopsy sites in proximity
  • Presence of old scars in proximity
  • Biopsy site is not visible to patient
  • Site information is not standardized when transmitted from biopsying physician to operating surgeon
  • Cancer had been completely removed by the biopsy itself but surgery is still performed

Proposed methods for correct biopsy site identification were considered for usefulness and feasibility. These included photography at the time of biopsy, held in the medical record and/or the patient’s cell phone; marking the site with UV fluorescent tattoos; mark the site on a standardized pre-printed diagram; identify site with detailed terminology for anatomic subunits; note the site in proximity to two other landmarks using ruler measurements.

The information that was pooled and processed concluded several of the best preventive interventions:

  • Photographs at the time of biopsy
  • Multiple photographs in association with landmarks and diagrams
  • Before operating, have patient point to biopsy site
  • Operating surgeon must ensure that all pertinent site identification information has been received from biopsying physician’s office
  • If there is not a strong consensus between the patient’s memory and the surgeon’s paperwork as to where the biopsy site is located, surgery should be postponed and the biopsying physicians office should be re-contacted
  • Patient and surgeon should confirm and reconfirm site to avoid miscommunication

With the results from this study, further research can now be conducted on the most appropriate and helpful of these preventative interventions. The researchers also note that the advances in technology may create new and innovative methods.

Source: JAMA Dermatol. Published online March 05, 2014. doi:10.1001

Image: UCD Medicine

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