This document discusses a case of wrong-site surgery where a man had his left kidney removed instead of the right kidney that had renal cell carcinoma. There were multiple errors that contributed to this including incorrect documentation, lack of imaging, and proceeding with surgery without the labeled images present. The Universal Protocol aims to prevent wrong-site surgery but requires strict implementation of verification, site marking, and a timeout. While it aims to help, wrong-site surgery still occurs, suggesting protocols need reinforcement.

1. Spotlight
Two Wrongs Don't Make a Right
(Kidney)

2. • This presentation is based on the March 2015
AHRQ WebM&M Spotlight Case
– See the full article at http://webmm.ahrq.gov
– CME credit is available
• Commentary by: John G. DeVine, MD, Professor of
Orthopaedic Surgery, Medical College of Georgia
– Editor, AHRQ WebM&M: Robert Wachter, MD
– Spotlight Editor: Bradley A. Sharpe, MD
– Managing Editor: Erin Hartman, MS
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Source and Credits

3. Objectives
At the conclusion of this educational activity,
participants should be able to:
• Review current definition of wrong-site surgery
• Describe the incidence of wrong-site surgery,
and the impact the Universal Protocol has had
on preventing wrong-site surgery
• Relate the key contributing factors to wrong-site
surgery
• Discuss the current best practices to prevent
wrong-site surgery
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4. Case: Two Wrongs Don't Make a Right
A 53-year-old man presented to Hospital A with abdominal pain
and hematuria. Computed tomography (CT) imaging revealed a
suspected renal cell carcinoma in the right kidney. He was
transferred to Hospital B for surgical management.
All of the medical records from Hospital A documented a left-
sided tumor—the wrong side. The CT scan from Hospital A was
not available at the time of transfer and repeat imaging was not
obtained by providers at Hospital B.
At the time of surgery, the surgeon was asked if the absence of
an available image should preclude progressing with the
surgery. He decided to proceed and, based on the available
information, removed the left kidney.
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5. Case: Two Wrongs Don't Make a Right (2)
The day following the surgery, the pathologist
contacted the surgeon to report no evidence of
cancer. The surgeon then reviewed the initial CT scan
and realized his mistake. The patient underwent a
second surgical procedure to remove the right kidney
(which was found to have renal cell carcinoma).
Having lost both kidneys, the patient was then
dependent on dialysis, and because of the cancer, he
was not a candidate for kidney transplant.
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6. Background: Wrong-Site Surgery
• The Joint Commission defines wrong-site
surgery as
– Any surgery performed on the wrong site
– Any procedure performed on the wrong patient
– Performance of the wrong procedure
• Wrong-site surgery is a sentinel event—an
unexpected occurrence involving death or
serious physical or psychological injuries, or
risk thereof
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7. Types of Wrong-Site Surgery
• Multiple subclassifications of wrong-site
surgery:
– Wrong level or part surgery (e.g., lumbar
discectomy on the incorrect level)
– Wrong-patient surgery
– Wrong-side surgery
– Wrong-level exposure
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8. Contributing Factors & Root Causes
• Most wrong-site surgeries have multiple
contributing factors and root causes
• For wrong-site surgery events reported to The
Joint Commission from 2004 to 2014, the top
3 root cause categories were:
– Leadership
– Communication
– Human Factors
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9. Contributing Factors & Root Causes (2)
• In a recent systematic review, contributing
factors to wrong-site surgery included:
– Incorrect patient positioning or preparation of the
operative site
– Incorrect or lack of consent
– Failure to use site markings
– Surgeon fatigue
– Multiple surgeons
– Unusual time pressures
– Overall poor communication
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10. The Universal Protocol
• The "Universal Protocol for Preventing Wrong
Site, Wrong Procedure, and Wrong Person
Surgery" became effective in July 2004
• The protocol applies to all accredited
hospitals, ambulatory care, and office-based
surgery facilities
• The Universal Protocol was designed to
engage institutions in implementing a
standardized approach to surgeries and
procedures
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11. The Universal Protocol (2)
• The protocol includes many recommended
steps but there are three principal elements
1) Preprocedure verification
2) Site marking
3) Time out prior to incision
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12. Frequency of Wrong-Site Surgery
• Between 1995 and 2005, wrong-site surgery
was the second most frequently reported
sentinel event
• Despite implementing the Universal Protocol in
2004, wrong-site surgery remains the second
most frequently reported event in 2014
– Wrong-site surgery accounted for 12.8% of
sentinel events from 2004 to 2014
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13. Frequency of Wrong-Site Surgery (2)
• Yet, these events are self-reported so likely
represent a small proportion of actual events
• Calculating the true frequency of wrong-site
surgery has been difficult
– Estimated rate of wrong-site surgery varies
widely, ranging from 0.09 to 4.5 per 10,000 cases
performed
• Most patient safety experts would maintain
that even one wrong-site surgery is too many
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14. This Case
• There appear to be four errors that resulted in
this sentinel event:
– A documentation error on the medical records
from Hospital A
– Only the records but not the actual imaging
accompanied the patient at the time of transfer
– The patient went to the operating room without
preoperative imaging
– The labeled radiology images were not present in
the operating room at the time of surgery
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15. This Case (2)
• The error in this case could have been
prevented even after the first 3 errors
• The Universal Protocol suggests having the
labeled radiology present in the operating
room at the time of the surgery
• The surgeon proceeded without the imaging,
leading to the adverse event
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16. Preventing Wrong-Site Surgery
• Despite widespread implementation of the
protocol, no evidence exists to substantiate
the effectiveness of the Universal Protocol in
preventing wrong-site surgery
• Yet, there is no evidence to support other
interventions
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17. Preventing Wrong-Site Surgery (2)
• The Joint Commission does support
modification of the protocol by specific
surgical specialties
• For example, the North American Spine
Society has recommended that, in addition to
the Universal Protocol, intraoperative imaging
following exposure and marking a fixed
anatomic structure should be used to
determine the correct level of spine surgery
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18. Other Interventions
• Other interventions may have
prevented error in this case
• For example, there could be
a hospital policy requiring
imaging to be present in the
operating room
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19. Summary
• The Universal Protocol can be a useful tool in
preventing wrong-site surgery, but the
implementation can be variable
• Health care administrators, providers, and
surgeons should ensure the protocol is
implemented as intended
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20. Take-Home Points
• Wrong-site surgery should be preventable
• Estimated rate of wrong-site surgery varies widely
ranging from 0.09 to 4.5 per 10,000 cases
performed
• Wrong-site surgery remains the second most
frequent sentinel event reported to The Joint
Commission
• The Universal Protocol has been in effect since July
2004 for all accredited organizations providing
surgical care. The protocol's effectiveness is only as
good as the policies guiding its use and the
personnel charged with applying those policies.
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