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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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A Look at The Joint Commission

Study Analyzes Wrong-Site Surgery Data in Medical Malpractice Complaints

Lenworth M. Jacobs Jr., MD, MPH, FACS

June 7, 2023

While strides continue to be made to reduce wrong-site surgeries, these events persist despite being considered “never events” in healthcare. Wrong-site surgeries are events that can cause serious and possibly permanent medical or emotional harm to a patient, including death.

To understand why these events continue to occur even though there have been many efforts by organizations such as The Joint Commission to reduce them, researchers analyzed closed medical malpractice claims pertaining to wrong-site surgeries during a period of 7 years. The findings were published in an article, “A Contemporary Analysis of Closed Claims Related to Wrong-Site Surgery,” in the May issue of The Joint Commission Journal on Quality and Patient Safety.*

From 1995 to 2005, The Joint Commission found that wrong-site surgery was the second-most frequently reported sentinel event, which is defined as “a patient safety event that results in death, permanent harm, or severe temporary harm.” These data were a factor in The Joint Commission implementing the Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery in 2003 that involves three important steps:

  • Conducting a preprocedure verification process
  • Marking the procedure site
  • Performing a time-out

However, wrong-site surgeries were still happening. In 2022, wrong-site surgery accounted for 6% of the 1,441 sentinel events reviewed by The Joint Commission. Reporting of sentinel events to The Joint Commission is voluntary, meaning no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

To further understand some of the reasons why wrong-site surgeries continue to occur, Joy Tan, MD, and coauthors reviewed a medical malpractice company’s closed claims data from 2013 to 2020.*

“Analysis of malpractice claims can help risk managers and clinicians identify risk factors, patterns, and other circumstances of [wrong-site surgery] with the goal of improving patient safety by identifying interventions to mitigate these risk factors,” the study authors wrote.

In total, 68 wrong-site surgery closed claims cases were examined, revealing:

  • The mean age of patients was 55.7 years.
  • Average indemnity was $136,452.84, and approximately 60% of the cases were settled.
  • The services most frequently responsible for the wrong-site surgery claims were orthopaedic (35.3%), neurosurgery (22.1%), and urology (8.8%).
  • The most common types of procedures that involved wrong-site surgery were spine surgery, including spinal fusion and excision of intervertebral disc (22.1%); arthroscopy (14.7%); and procedures on muscles and/or tendons (11.8%).

Researchers also found that the most common alleged injuries included the need for additional surgery (45.6%), pain (33.8%), mobility dysfunction (10.3%), aggravated/worsened injury (8.8%), death (7.4%), total loss (7.4%), and scarring (7.4%).

“Our data show that most [wrong-site surgeries] caused significant harm to the patient, with 30.9% causing temporary minor harm, 23.5% causing temporary major harm, and 17.6% causing permanent minor harm,” the study authors stated.

The top contributing factors to wrong-site surgery were:

  • Failure to follow policy/protocol
  • Failure to read medical records
  • Selection/management of surgical treatment
  • Inconsistent documentation
  • Known complications or technical issues
  • Communication among providers

“Across all surgeries, the overwhelming top contributing factor to [wrong-site surgery] was failure to follow policy/protocol…[but] only 14.7% of claims were related to a need for policy/ protocol,” the study authors wrote. “This suggests the main issue lies not in creating policies but in the implementation of a policy/protocol, including the use of the World Health Organization’s Surgical Safety Checklist. Indeed, safety measures need to be followed to prevent errors, and determining why they are not being used is key.”

The study authors concluded that healthcare teams must be “more diligent in performing these checklists” without distraction or shortcuts.

“This can effectively be done only with a culture of safety and effective communication among the team,” they wrote. “This includes the patient themselves taking more ownership of their medical care. With these efforts, we can significantly reduce the incidence of these events.”

An accompanying editorial published in the Journal, “Understanding A Surgeon’s Worst Nightmare: Wrong Site Surgery,” by Tyler P. Robinson, MD, and coauthors expanded on the potential impact of a healthcare team’s failure to follow the established protocol in relation to wrong-site surgeries.

“When a [wrong-site surgery] event occurs, clinicians must be prepared to investigate and disclose these errors to maintain trust among patients and the community at large,” the editorial authors wrote. “Hospital-level investigation must occur, utilizing methods such as a root cause analysis. Root cause analysis can identify solutions to bolster adherence to the Universal Protocol and incorporate other processes to improve safety.” ‡ 


The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

Dr. Lenworth Jacobs is a professor of surgery and professor of traumatology and emergency medicine at the University of Connecticut and director of the Trauma Institute at Hartford Hospital, CT. He also is the Medical Director of the ACS STOP THE BLEED® program.

*Tan J, Ross JM, Wright D, et al. A contemporary analysis of closed claims related to wrong-site surgery. Jt Comm J Qual Patient Saf. 2023;49(5):265-273.

The Joint Commission. The Joint Commission releases sentinel event data on serious adverse events at US healthcare organizations. April 4, 2023. Available at: https://www.jointcommission.org/resources/news-and-multimedia/news/2023/04/the-joint-commission-releases-sentinel-event-data. Accessed May 31, 2023.

Robinson TP, Bilimoria KY, Yang AD. Understanding a surgeon’s worst nightmare: Wrong site surgery. Jt Comm J Qual Patient Saf. 2023;49(5):237-238.