Wrong Site Surgery Problems Are Most Common During Spinal, Orthopedic Procedures: Report

A recent report that examined medical malpractice claims stemming from wrong-site operations filed in recent years highlights how errors spinal surgery to the wrong part of the body are still far too common, despite precautionary guidelines that are in place.

According to an analysis published in the May edition of The Joint Commission Journal on Quality and Patient Safety, almost 70 wrong site closed claims cases were filed with just one medical malpractice company between 2013 and 2020.

The analysis reveals how wrong site surgical errors most frequently happen during orthopedic, neurosurgery, and urology services, with spine and intervertebral disc procedures the most likely to result in wrong site malpractice claims.

Wrong Site Surgery Risks Increase with Spinal Procedures

To complete their analysis, researchers examined closed claims statistics on wrong site surgery lawsuits, including data on procedures between 2013 and 2020.

The data showed that during those seven years, there were 68 wrong site closed claims identified. The average age of the affected patients was 55, and female patients were about 1.5% more likely to encounter a wrong site surgery problem then men.

Researchers indicate that inpatient settings are more likely to result in a wrong site surgery event, compared to ambulatory or outpatient environments.

Orthopedic services were the riskiest medical service for wrong site surgery problems, with over 35% of the closed claims cases stemming from procedures in this category. Neurosurgery services were the second most dangerous group containing over 22% of closed wrong site surgery claims. Urology services were also identified as high risk, with nearly 9% of closed medical malpractice claims filed due to surgical errors in this category.

Specific surgical procedures were also examined to determine a wrong site surgery risk ratio. Spinal surgery, including intervertebral disc procedures, was the most common surgery cited in the closed claims cases, at 22.1%. Arthroscopy surgery was involved in 14.7% of the closed claim cases, and muscle/tendon surgery also had a high-risk wrong site surgery rate, with nearly 12% of wrong site surgery medical malpractice claims filed as a result of that type of surgery.

Researchers concluded that the heightened risk of a wrong site surgery in spinal procedures appears to be the result of unique and highly complex technical skills required for this body region.

Doctors Routinely Fail to Follow Protective Protocols

As part of the study, researchers also examined why wrong site surgical errors are still occurring as often as they do, despite the implementation of a universal protocol in 2003, which are intended to prevent such catastrophic medical mistakes, which are considered “never events”, that are entirely preventable through the exercise of proper standards of care.

Researchers determined that in almost 84% of the wrong site surgery claims examined, doctors failed to adhere to the universal protocol when prepping for and performing the surgery. Specifically, in over 41% of the closed claims cases, doctors did not review prior patient medical records to confirm the correct body site for the scheduled procedure.

The data analysis also shows that patients experiencing wrong site surgery problems endure significant physical consequences. Almost 46% of the wrong site surgery victims examined in the study needed a second corrective surgery, and nearly 34% suffered chronic pain. Over 10% experienced a loss of mobility. More than 7% of the wrong site surgeries examined resulted in fatal complications.

Wrong Site Surgical Error Medical Malpractice Settlements

The average closed claim value of the medical malpractice cases examined in the study was $136,452.84. Wrong site surgery medical malpractice lawsuits usually allege that wrong site mistakes are “never events” that should not occur under any circumstances and therefore merit a significant damage award.

The report stated that wrong site surgery is the fifth most common catastrophic medical error, or “sentinel event,” in the U.S. Between 2005 and 2021, a total of 14,731 of these sentinel events were reported, resulting in the following patient outcomes;

• 45.93% resulted in patient death
• 24.25% resulted in unexpected additional care needed
• 11.58% resulted in severe temporary harm
• 5.83 % resulted in permanent loss of function
• 2.23% resulted in psychological harm
• 2% resulting in permanent harm
• 8.17% of events were unknown/unassigned or categorized as other.

In addition to negligence in following proper surgical protocols, recent research suggests that lack of attention and memory lapses during medical procedures are also a common cause of surgical mistakes and medical adverse events.