Surgeons urged to sign patients to avoid surgery on the wrong site

Signature or initials said to greatly reduce chance of tragic error

Wrong-site surgery sometimes is considered such a ridiculous and rare foul-up that there is no need to institute measures to prevent it, but a growing chorus of surgeons and legal experts is advocating a simple solution they say can practically eliminate the problem: The surgeon should sign his or her name directly on the body part to be operated on.

The idea has been around for a while, but it has received more attention in recent years after several wrong-site surgery incidents gained wide spread media attention. In two notorious cases, a surgeon amputated the wrong leg of a patient, and another surgeon opened the wrong side of a patient’s head for brain surgery. Like almost all cases of wrong-site surgery, the mistakes were traced to simple errors in the pre-op system that led the surgeon and staff to proceed on the wrong site.

That sort of mistake can be eliminated almost entirely by requiring surgeons to sign their patients before surgery, says Terry Canale, MD, chief of staff at the Campbell Clinic in Germantown, TN, where all 30 orthopedic surgeons and 32 residents sign their patients before surgery. Canale also leads the ongoing campaign by the American Academy of Ortho paedic Surgeons (AAOS) to eliminate wrong-site surgery. He chaired an AAOS task force that determined the problem is more widespread and serious than many believed, and he says the signing policy is the solution.

"This happens more than we might like to admit, and every damn one of them is prevent able, and every one is going to be a lawsuit," he says. "Here’s a complication that’s totally preventable. We can knock this out totally like the polio vaccine knocked out polio."

The AAOS task force found that, contrary to common belief, wrong-site surgery is not just a rare, freak accident. Using data supplied by the Physicians Insurers Association of America (PIAA) and compiled by 22 malpractice insurers, the AAOS found 326 claims for wrong-site surgery between 1985 and 1995, with two-thirds originating in orthopedics. Of the 225 orthopedic claims, 84% resulted in payment, with an average payment of $48,087 and a median payment of $20,000. Of the 106 claims from other specialties, 68% resulted in payment, with an average of $76,167 and a median of $25,000.

Wrong-site surgery claims are far more likely to result in payment, according to the AAOS and PIAA, with a whopping 84% paid instead of the 30% average in all orthopedic malpractice claims.

Using a database of 37 wrong-site surgery claims from the State Volunteer Mutual Insurance Co. in Tennessee, the AAOS determined that an error was discovered during surgery in 60% of cases, and the originally planned procedure was carried out in the correct location while under the same anesthesia. Twenty-six patients had no residual deficit other than cosmetic effects, but others suffered impairment at the operative site, permanent disability, and other effects.

In each of 18 cases, financial liability was shared by the doctor and the hospital. The physician or physician group was solely responsible in nine cases, and 10 other cases remain open.

Using the Tennessee database and extrapolating its numbers to all orthopedic surgeons in the state, the AAOS estimates that an orthopedic surgeon’s chance of performing wrong-site surgery during a 35-year career is one in four.

"That’s a fairly devastating number," Canale says, adding that there is an additional risk beyond the obvious one to the patient and the financial one to the health care provider: The surgeon suffers greatly after such an incident, he says.

"For the surgeon, it is psychologically devastating to have operated on the wrong side," he says. "I’ve seen guys mope around for six months afterward with a terrible inferiority complex, just totally paranoid about making another mistake."

An attorney who is familiar with wrong-site surgery litigation agrees with Canale that the practice of signing patients could virtually eliminate the surgical gaffe. Harvey Wachsman, MD, JD, is involved with both the clinical and legal sides of the debate. As a trustee of the State University of New York, he directs several medical programs at the university’s facilities and is a practicing neurosurgeon. He also is president of the American Board of Professional Liability Attorneys and one of the best-known medical malpractice attorneys in the country. He recently represented the woman who had to undergo a second round of brain surgery to remove a tumor after the first procedure was done on the wrong side.

Signing patient reduces liability

Wachsman says signing patients is a good policy. Right-left confusion is an easy mistake for even the most skilled surgeon, he says, and experience has shown that it only takes one small error to cause wrong-site surgery. He adheres to a policy of signing patients and encourages all his colleagues to do the same.

"This policy would have prevented the cases of wrong-site surgery that we know of," Wachsman says. "The extra few minutes that are involved are negligible, and it’s to everyone’s benefit."

A number of hospitals have adopted the practice recently, including New York University, Chicago’s Northwestern University Medical Center, and Strong Memorial Hospital in Roch ester, NY. Many hospitals encourage the practice but do not make it mandatory. Canale and Wachs man say they would be pleased to see mandatory marking policies at all hospitals, but the AAOS task force determined it was beyond its scope to recommend such policies.

Canale and Wachsman say they know of no surgery performed on the wrong site after signing a patient. While the risk seems greatest with orthopedic and neurosurgical procedures, the doctors say the principle applies to any surgical procedure. Patient signing could be extended even to general surgery to avoid performing the wrong procedure or operating on the wrong patient.

Growing acceptance among surgeons

Canale provided Healthcare Risk Management with a sneak preview of the results of a survey of the 17,000 members of AAOS, which show that 40% of them routinely sign patients before surgery. That is the result of a nine-month campaign by the AAOS to encourage the practice, and Canale has mixed emotions about the 40% participation. While he recognizes that it is significant to change the behavior of 40% of a population in only nine months, he says he is a bit disappointed that more surgeons are not adopting such a good solution.

Patients love the idea, he says, because they have heard the horror stories about wrong-site surgery. Surgeons come to rely on the practice, even if they are reluctant to begin it, he says. The only downside to the practice is the extra few minutes it takes for the surgeon to verify the correct location and sign the patient, but Canale says that is a minimal price for the security offered. Many surgeons use the moment to converse with the patient, calm fears, and establish more rapport.

The Joint Commission on the Accreditation of Healthcare Organizations has expressed interest in the signing policy, Canale says. The Joint Commis sion has made wrong-site surgery an automatic sentinel event, so it may look favorably on a signing policy.

Canale says the act of signing the body part does no good if you have not confirmed the surgery location. The real benefit from the signing is that the surgeon has taken personal responsibility, before the patient is prepared and draped, for confirming the correct site. (See related story at right.) The act of signing requires the surgeon to confirm the site instead of leaving it to others and possibly compounding the error by assuming the patient is draped correctly. "You’ll hear surgeons say they’re too busy for this kind of thing, and they’ll try to send down a third assistant or the youngest nurse they can find to do it for them," he says. "Those are the people we need to convince the most. They’re the people most at risk of making the error in the first place."