![]() Some state licensure boards have introduced heavy penalties to surgeons responsible for wrong site surgeries (Mulloy & Hughes, 2008). For instance, 79% of all wrong site surgeries of the eye and 84% of all wrong site orthopedic surgeries were compensable after being filed as malpractice claims. ![]() Wrong site and wrong person surgeries are both considered compensable under healthcare malpractice claims. Wrong site surgery has negative consequences, both to the patient as well as the surgical team and healthcare providers (Banja, 2005). The leading risk factors that contributed to wrong site surgeries were multiple surgeons, obesity, emergency cases, time pressures, deformities, multiple procedures, room changes, and unusual equipment. Of the causes identified, the leading causes of wrong site surgery were communication failures 70%, procedural noncompliance 64%, and leadership failures 46% (Mulloy & Hughes, 2008). These causes were identified through a root-cause analysis process aimed at establishing the major underlying organizational factors and causes that resulted in a wrong site surgery. The Joint Commission undertook the wrong-site surgery project in July 2009 and identified 29 major causes of wrong site surgeries (Becker’s healthcare, 2011). Most wrong site surgery cases occur due to the deficiency in a formal system that can be used to ascertain the appropriate site of surgery or the inefficiency of the system utilized to verify the suitable site of surgery. Faulty systems and poorly designed healthcare processes contribute to the occurrence of medical errors. Other issues that result to medical errors include poor communication, poor nurse-to-patient percentages, and improper documentation. ![]() Most medical errors commonly arise due to inexperienced nurses and physicians, urgency of healthcare, use of new procedures, and the extremes of age. Most medical errors occur because of human errors in the course of healthcare provision, which accounts for about 80% of all medical errors (Banja, 2005). This number was attained through the Robust Process Improvement methodology, which is a systematic, fact-based, and data driven approach that uses methods and tools from change management and six sigma strategies. These include performing surgery on wrong site, wrong side and the wrong patient as well as performing wrong surgery procedure (O’reilly, 2013). According Joint Commission Center for Transforming Healthcare there is an average of forty WSS occurring every week in United States. Statistics indicate that most of WSS occur in general surgery, orthopedic procedures, neurosurgical procedures and urological procedures. Since the inception Joint Commission Sentinel Event program, the number of WSS reported increased from 15 cases in 1998 to 592 reported cases in 2007. Although WSS have been rare events for many years, their prevalence is increasing in recent years. Despite this, the number of wrong site surgery cases reported has been increasing over the years. As such, it is estimated that only 10% of all wrong site surgeries are reported, with the number of wrong site surgeries reported to the Joint Commission being lower than other wrong site surgery statistics from other sources. Wrong site surgery cases are considered as sentinel events and reporting of such cases to the Joint Commission is on voluntary basis (Banja, 2005). This paper will focus on the occurrence of wrong site surgery from the legal and ethical perspective as well as the actions being taken to arrest the rising cases of wrong site surgery. A wrong site surgery can occur mainly under three subcategories namely incorrect side, correct side but wrong location, and both correct side and location but wrong surgery operation (Fraser & Adams, 2006). A surgery is considered a wrong site surgery once it is identified any moment after the commencement of the surgery and which results in the need for additional surgery on the appropriate site. A wrong site surgery refers to a surgery procedure that is carried out on the wrong or incorrect site (Banja, 2005). ![]() Such events are referred to as sentinel because their occurrence calls for a quick response as well as investigation.Ī wrong sight surgery (WSS) is one of the sentinel events in healthcare. A sentinel event may also involve severe temporary injury that may require intervention to sustain life. A serious injury in this case may involve a loss of an organ such as limb, hand or a particular function. A sentinel event involves the occurrence of an unexpected event that may involve death, a serious physical/psychological harm or a big risk thereof.
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