Wrong Site Surgery or Procedure
In this assignment, you will select a program, quality improvement initiative, or other
project from your place of employment. Assume you are presenting this program to the
board for approval of funding. Write an executive summary (850-1,000 words) to present
to the board, from which they will make their decision to fund your program or project.
The summary should include:
1) The purpose of the program or project.
2) The target population or audience.
3) The benefits of the program or project
4) The cost or budget justification.
5) The basis upon which the program or project will be evaluated.
Prepare this assignment according to the APA guidelines found in the APA Style Guide,
located in the Student Success Center. An abstract is not required.
Surgical Wrong Site Surgeries or Wrong Procedures: An Executive Summary
Reporting of wrong site surgery is rare in most states but I decided to write this report so
as to transform the health care and to improve the safeguard so as to prevent the patients from
wrong site surgery. I would like this to reach as many people as possible especially all the
surgeons because they will get informed on the ways to reduce risk of wrong site, wrong
procedure and wrong patient surgery. This project will be evaluated on whether I have been able
to put down the causes of wrong site surgery and the measures to be observed to eliminate it. I
expect 30000$ for this report because it will be of benefit to many people through learning ways
of protecting the lives of people.
Wrong site surgery is caused by lack of institutional control, poor preoperative planning
or failure of the surgeon to exercise due care. It affects both the patient and the surgeon. It may
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also be caused by a very simple mistake from communication between the surgeon and the
patient. Wrong site surgery is a system problem which goes to an extent of affecting other
surgical specialties. It is not just an orthopedic problem that happens because the surgeon
operated the wrong limb (Mulloy & Hughes, 2008).
The number of orthopedic surgery cases reported is not high compared to the total
number of orthopedic professional liability insurance claims. 84% of cases involving wrong site
orthopedic surgery normally results in indemnity periods over 10 year period compared to all the
other types of orthopedic surgery claims where indemnity periods are completed in 30% of
orthopedic surgery claims over the same duration (Mulloy & Hughes, 2008). Wrong site
surgeries are very rare but they continue to occur despite the campaigns against them. However,
the Canadian orthopedic association provided a very vital program to eliminate the problem and
it worked because the number of cases of orthopedic surgery claims are said to have reduced in
Canada (Mulloy & Hughes, 2008).
The state licensure boards are introducing penalties on surgeons for the wrong site
surgery. The insurers may also take the action of not insuring the life of “wrong person’s
surgery” (Mulloy & Hughes, 2008). The surgeon responsible for the wrong site surgery is being
held responsible for the act and is supposed to compensate because it is said to have malpractice
claims (Mulloy & Hughes, 2008).Cases of wrong site surgery have recently increased compared
to the previous years. The number is said to have increased from 15 cases recorded in 1998 to
592 cases recorded in 2007 (Mulloy & Hughes, 2008). This research has been conducted by the
Joint Commission’s Sentinel Event program. Wrong site surgery mostly occurs during general
surgery, urological and neurosurgical procedures.
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Generally, wrong site surgery is caused by lack of a formal system used to verify the site
of the surgery or the failure of the system which is normally used to confirm the correct size of
the surgery. Other factors may include: inadequate patient assessment, lack of care planning,
lack of medical record review, miscommunication among the surgical team members, when
multiple procedures are performed to a patient in a single operation, where more than one
surgeon is involved in an operation, where the patients or the family members are not included
when identifying the correct site for the surgery, where there is no clear mark of the site of the
operation, noncompliance with the procedures involved during the surgery and the failure of the
surgical team to recheck the patient’s information before starting the operation (Mulloy &
Attempts to address the occurrence of wrong site surgery were started by the American
academy of orthopedic surgeons and the North American spine society. The American academy
of orthopedic surgeons made campaigns to create awareness of marking the correct site if the
surgery which was called: ’sign your site’ (Mulloy & Hughes, 2008). The north American spine
society later polished the sign your site program and made if more effective by adding more
details and making it “sign, mark, and X-ray “ program whose main aim was to emphasize on
marking of the right site and follow the correct procedures as required. Later in 2003, the joint
commission organized a conference which included the American academy of the orthopedic
surgeons and leaders of 23 other organizations which were related (Mulloy & Hughes, 2008).
The conference was to address on the increasing cases of the wrong site surgery and how
to eliminate them and the impact the wrong site surgery has on the patients, their families, and
the surgeons involved in the operations. The group came up with a protocol “The Universal
Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery” (Mulloy &
SURGICAL WRONG SITE SURGERIES OR WRONG PROCEDURES 4
Hughes, 2008). The goal of this protocol was to eliminate the highly growing number of cases of
wrong site surgeries. It was to be used in all zones where aggressive procedures are done within
the health care societies. This protocol was composed of three key elements which were:
preoperative verification process, marking the operative site and taking a time out (Mulloy &
This universal protocol was to be used in hospitals, ambulatory care and critical access
hospitals. Obedience to the protocol was to lead to elimination of wrong site surgery. The
association of perioperative registered nurses realized the importance of the universal protocol of
the wrong site surgery and decided to work hand in hand with them to make the correct site
surgery tool kit to help those who provide health care implement the universal protocol for the
wrong site surgery. The universal protocol of the wring site surgery has had a positive impact.
Nearly half of the surgeons have responded to the sign your site campaign by changing their
preoperative practices. At least two thirds of the wring site surgeries have been prevented but it
was impossible to prevent the one third of the wrong site surgery because of the errors which
might have occurred before the operation. The surgery center leaders have a role to play in
eliminating the wrong site surgery. They should evaluate their procedures and ensure they mark
the correct site to eliminate the wrong site surgery completely. All the health care professionals
have a duty to observe the rules of the universal protocol and they should feel free to speak up if
they see that the wellbeing of the patient is at risk (Mulloy & Hughes, 2008).
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Mulloy, D. F., & Hughes, R. G. (2008). Wrong-site surgery: a preventable medical error. Patient
Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for
Healthcare Research and Quality.