Closed Claims Data Analysis Identifies Wrong-Site Surgery Risk Factors

Wrong-site surgeries (WSS) can cause serious medical and emotional harm, as well as significant financial and legal consequences for patients and healthcare providers. While the incidence of WSS is low, it caused 7.9% of sentinel events voluntarily reported to The Joint Commission from 2018 to 2021.

A new study in the May 2023 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS) analyzed closed claims data on WSS to identify risk factors, patterns and other circumstances of WSS. The claims were classified by allegations made by claimants, responsible services, types of procedures, injuries and contributing factors. Researchers performed a descriptive analysis of the variables and reviewed the clinical summary of each case.

The study reviewed 68 WSS closed claims cases from 2013 to 2020. Findings showed the services most frequently responsible for these cases were orthopedic (35.3%), neurosurgery (22.1%) and urology (8.8%). The most common types of procedures involving WSS were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%) and surgery on muscles/tendons, most commonly hand surgery (11.8%).

Additionally, the researchers found the severity of claims was higher in the inpatient setting compared to the ambulatory care setting. The most common alleged injuries included the need for additional surgery (45.6%), pain (33.8%), mobility dysfunction (10.3%), worsened injury (8.8%) and death (7.4%). The top contributing factors to WSS were failure to follow policy/protocol (83.8%) and failure to review medical records (41.4%).

“WSS is a preventable injury that can severely harm patients and is a critical topic that must be addressed in providing best patient care,” notes an accompanying editorial. “Despite efforts to reduce this sentinel event, WSS persists. Healthcare systems and practitioners should continue to study WSS events, look to implement new methods to prevent WSS and continue to work toward achieving the goal of making WSS a true never-event.”

For more information, please visit the JQPS website.