Joint Commission study explores wrong-site surgery risk factors, trends

Orthopedic services are the most frequently cited in wrong-site surgery claims, according to an analysis of closed claims data published in the May edition of The Joint Commission Journal on Quality and Patient Safety.

The findings are based on researchers' analysis of 68 wrong-site surgery closed claims cases from 2013 to 2020. Patients' mean age was about 56. Overall, the severity of claims was higher in the inpatient setting relative to the ambulatory care setting.  

Four findings: 

  • Orthopedic services (35.3 percent) were the most frequently cited service in the closed claims, followed by neurosurgery (22.1 percent) and urology (8.8 percent). 
  • The most common types of procedures on the claims were intervertebral disc surgery (22.1 percent), arthroscopy (14.7 percent) and surgery on the muscles/tendons (11.8 percent).
  • The need for additional surgery was the most common alleged injury, making up about 46 percent of claims.
  • Failure to follow policy/protocol (83.8 percent) and failure to review medical records (41.2 percent) were the top contributing factors to WSS. 

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