Incidence of wrong-site surgery among hand surgeons

J Bone Joint Surg Am. 2003 Feb;85(2):193-7. doi: 10.2106/00004623-200302000-00002.


Background: Until recently, wrong-site surgery had received little attention and had been considered a random, infrequent event. In 1997, the American Academy of Orthopaedic Surgeons (AAOS) Task Force on Wrong-Site Surgery was formed to determine the incidence of wrong-site surgery and to initiate the "Sign Your Site" campaign. The purpose of our study was to determine the incidence of wrong-site surgery among hand surgeons, elucidate surgeons' practice habits and measures taken to prevent its occurrence, and evaluate the effectiveness of the AAOS "Sign Your Site" campaign.

Methods: One thousand, five hundred and sixty active members of the American Society for Surgery of the Hand (ASSH) were polled by mail. Each member received a confidential twenty-nine-question survey. Nonrespondents were sent a second, identical survey. One thousand and fifty (67%) of the surgeons responded.

Results: One hundred and seventy-three surgeons (16%) reported that they had prepared to operate on the wrong site but then noticed the error prior to the incision, and 217 (21%) reported performing wrong-site surgery at least once. Of an estimated 6,700,000 surgical procedures, 242 were performed at the wrong site, an incidence of one in 27,686 procedures. The three most common locations of wrong-site surgery were the fingers (153), hands (twenty), and wrists (twenty-one). Permanent disability occurred in twenty-one patients (9%). Ninety-three cases (38%) led to legal action or monetary settlement. Seventy percent of the responding orthopaedic surgeons were aware of the "Sign Your Site" campaign, and 45% had changed their practice habits as a result.

Conclusions: Prior to the AAOS "Sign Your Site" campaign, the issue of wrong-site surgery by hand surgeons had not been addressed. Although wrong-site surgery is rare, 21% of hand surgeons reported performing it at least once during their careers. Since the institution of the "Sign Your Site" campaign, 45% of orthopaedic hand surgeons have changed their practice habits, and almost all routinely take some action to prevent wrong-site surgery.

MeSH terms

  • Hand / surgery*
  • Humans
  • Incidence
  • Medical Errors / legislation & jurisprudence
  • Medical Errors / prevention & control*
  • Medical Errors / statistics & numerical data*
  • Orthopedics / standards*
  • Professional Practice / legislation & jurisprudence
  • Professional Practice / standards*
  • United States