Background: The concept of "Sign Your Site" was established in 1997 to prevent wrong-site surgery in the U.S., and this was expanded to the mandated Universal Protocol in 2008. However, the true incidence of wrong-site surgery in the U.S. is not known, nor do we know whether the incidence has changed. The American Board of Orthopaedic Surgery (ABOS) requires that candidates for Board certification provide a list of their cases, including surgical complications, whether wrong-site surgery was performed, and whether they complied with the "Sign Your Site" practice. Each candidate attests to the accuracy of his or her notarized case list. The purpose of this study was to report the incidence and nature of wrong-site surgery self-reported by orthopaedic surgeon candidates for certification between 1999 and 2010 and to assess whether any change was associated with the timeline of implementation of the Universal Protocol.
Methods: The ABOS database was queried for the number of examinees, cases, and wrong-site surgery cases reported; a description of each wrong-site surgery case; whether the site was signed; and the surgeon's subspecialty.
Results: From 1999 through 2010, 9255 orthopaedic surgeons submitted 1,291,396 cases, and sixty-one of these surgeons reported performing seventy-six wrong-site surgical procedures. Spine surgeons were the most likely to report wrong-site surgery, most commonly single-level lumbar laminotomy. The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate was not significantly different. Eighteen of the twenty wrong-site surgical procedures performed since ABOS data collection for "Sign Your Site" began had been signed preoperatively.
Conclusions: Keeping patients safe remains an essential goal worthy of enormous effort. This study suggests that additional layers of precautions may yield diminishing returns and that attention should be focused on methods to prevent wrong-level spine surgery. Improving communication among the health-care team and shared responsibility may bring us closer to eliminating wrong-site surgery.