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, 157 (1), 48-52

Wrong-Site Surgery in California, 2007-2014

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Wrong-Site Surgery in California, 2007-2014

Omid Moshtaghi et al. Otolaryngol Head Neck Surg.

Abstract

Objective The implementation of a universal surgical safety protocol in 2004 was intended to minimize the prevalence of wrong-site surgery (WSS). However, complete elimination of WSS in the operating room continues to be a challenge. The purpose of this study is to evaluate the prevalence and etiology of WSS in the state of California. Study Design A retrospective study of all WSS reports investigated by the California Department of Public Health between 2007 and 2014. Methods Prevalence of overall and specialty-specific WSS, causative factors, and recommendations on further improvement are discussed. Results A total of 95 cases resulted in incident reports to the California Department of Public Health and were included in our study. The most common errors were operating on the wrong side of the patient's body (n = 60, 62%), performing the wrong procedure (n = 21, 21%), operating on the wrong body part (n = 12, 12%), and operating on the wrong patient (n = 2, 2%). WSS was most prevalent in orthopedic surgery (n = 33, 35%), followed by general surgery (n = 26, 27%) and neurosurgery (n = 16, 17%). All 3 otolaryngology WSS cases in California are associated with the ear. Conclusion WSS continues to surface despite national efforts to decrease its prevalence. Future research could establish best practices to avoid these "never events" in otolaryngology and other surgical specialties.

Keywords: complications; errors; surgery; surgical mistakes; timeout; wrong side; wrong site.

Conflict of interest statement

Competing interests: Hamid R. Djalilian, Mindset Technologies—owns stock; OticPharma—consultant.

Figures

Figure 1.
Figure 1.
The annual prevalence of wrong-site surgery (WSS) in California.
Figure 2.
Figure 2.
The percentage of wrong-site surgery (WSS) cases by(A) surgical specialty and (B) anatomic site.
Figure 3.
Figure 3.
Box and whisker plot of the average number of annual wrong-site surgery cases demonstrates no significant difference across various surgical specialties (California Department of Public Health [CDPH] data, 2007–2015). The red line within each box designates the median number of cases per year, with the upper and lower borders of the box corresponding to the upper and lower quartiles. The vertical lines extending from the boxes depict the highest and lowest values per year. The crosshair symbols designate outlier data points outside the quartile range.

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