Tan Joy, Ross Jacqueline M, Wright Daniel, Pimentel Marc Philip Tanedo, Urman Richard D
Jt Comm J Qual Patient Saf. 2023 May;49(5):265-273. doi: 10.1016/j.jcjq.2023.02.002. Epub 2023 Feb 11.
Wrong-site surgeries are considered "never events" and continue to occur despite the implementation of the Universal Protocol by The Joint Commission in 2003.
The authors reviewed closed claims data on wrong-site surgery between 2013 and 2020 from a medical malpractice company. The claims were classified by allegations made by claimants, the responsible services, the types of procedures, the injuries, and contributing factors. Researchers performed a descriptive analysis of the available variables and reviewed the clinical summary of each case.
Between 2013 and 2020, there were 68 wrong-site closed claims cases. The mean age of the patients was 55.7 (standard deviation 16.21) years, and 51.5% were female. The services most frequently responsible for these were Orthopedic (35.3%), Neurosurgery (22.1%), and Urology (8.8%). The most common types of procedures were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%), and surgery on muscles/tendons (11.8%). The severity of claims was higher in the inpatient setting compared to the ambulatory setting. The most common alleged injuries included the need for additional surgery (45.6%), pain (33.8%), mobility dysfunction (10.3%), worsened injury (8.8%), death (7.4%), and total loss (7.4%). The top contributing factors to wrong-site surgery were failure to follow policy/protocol (83.8%) and failure to review the medical records (41.2%). The mean closed claim value was $136,452.84, and 60.3% of cases were settled.
The risk of wrong-site surgeries is increased with spine surgeries, likely due to unique technical challenges. Further research is required to identify effective methods of prevention of these events.
尽管联合委员会于2003年实施了通用协议，但手术部位错误仍被视为“绝不应该发生的事件”，且此类事件仍在继续发生。
作者回顾了一家医疗事故公司2013年至2020年期间关于手术部位错误的已结案索赔数据。这些索赔根据索赔人的指控、责任科室、手术类型、损伤情况以及促成因素进行分类。研究人员对可用变量进行了描述性分析，并审查了每个病例的临床总结。
2013年至2020年期间，有68例手术部位错误的已结案索赔案件。患者的平均年龄为55.7岁（标准差16.21），51.5%为女性。对此类事件最常负责的科室是骨科（35.3%）、神经外科（22.1%）和泌尿外科（8.8%）。最常见的手术类型是脊柱和椎间盘手术（22.1%）、关节镜检查（14.7%）以及肌肉/肌腱手术（11.8%）。与门诊环境相比，住院环境中的索赔严重程度更高。最常见的指控损伤包括需要额外手术（45.6%）、疼痛（33.8%）、活动功能障碍（10.3%）、损伤加重（8.8%）、死亡（7.4%）和完全丧失（7.4%）。手术部位错误的首要促成因素是未遵循政策/协议（83.8%）和未查阅病历（41.2%）。已结案索赔的平均价值为136,452.84美元，60.3%的案件得到了和解。
脊柱手术中手术部位错误的风险增加，可能是由于独特的技术挑战。需要进一步研究以确定预防这些事件的有效方法。
