Why wrong site surgeries happen — 7 notes

Wrong-site surgeries are one of the most serious types of medical errors, known as sentinel events, and garner a lot of attention when they occur. 

Still, such incidents occur at some of the most esteemed hospitals and health systems. 

A kidney transplant mix-up at University Hospitals in Cleveland made headlines in July when a patient received a kidney meant for another patient. While the organ was compatible with the patient who received it, the incident delayed the procedure for the patient it was intended for and two caregivers were placed on administrative leave. 

So how do such severe mistakes, which are also costly to health systems, occur? The answer may lie in the rarity of such events, Medscape reports. 

Seven notes: 

1. "The problem is that it is so rare that doctors don't focus on it," Mary Kwaan, MD, a colorectal surgeon at UCLA Medical Center in Los Angeles, told Medscape

2. "Many surgeons don't think it can happen to them, so they don't take extra precautions," added David Mayer, MD, executive director of the MedStar Institute for Quality and Safety in Washington, D.C. "When they make a wrong-site error, usually the first thing they say is 'I never thought this would happen to me,'" he told the news outlet. 

3. Medscape cited a 2006 study led by Dr. Kwaan found that one wrong-site surgery occurs for every 112,994 surgeries performed. Those add up, with a separate 2006 study estimating between 25 and 52 such mistakes occur every week in the U.S. 

4. The mean malpractice payment for wrong-site surgeries in 2013 was $127,000, ranging based on the severity of the incident. Medcape cited a 2013 malpractice payment from a Maryland OB-GYN paid $1.42 million for removing the wrong ovary from a patient in 2009. 

5. More than 60 percent of surgeons who perform wrong-site surgeries are in their 40s and 60s, while less than 25 percent are younger than 40, according to a 2008 report cited by Medscape. 

6. Such errors are more common in certain specialties than others, with 25 percent of orthopedic surgeons reporting they performed at least one wrong-site surgery during their career, according to a study cited by Medscape.

7. In 2020, 68 wrong-site surgeries were reported to The Joint Commission, though such reports are given voluntarily and are likely an undercount. The accrediting agency believes its statistics account for less than 2 percent of all sentinel events that occur across the country's healthcare system.

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