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

2. Source and Credits
This presentation is based on the March 2015 AHRQ WebM&M Spotlight Case
See the full article at
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

3. Objectives Review current definition of wrong-site surgery
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

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.

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.

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
Facts about the Universal Protocol. Oakbrook Terrace, IL: The Joint Commission; 2014.

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
Facts about the Universal Protocol. Oakbrook Terrace, IL: The Joint Commission; 2014.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site surgery: a systematic review. Spine. 2010;35:S28-S36.

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
Sentinel Event Data: Root Causes by Event Type. Oakbrook Terrace, IL: The Joint Commission; Available at

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
DeVine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site surgery: a systematic review. Spine. 2010;35:S28-S36.

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
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The Joint Commission. Available at

11. The Universal Protocol (2)
The protocol includes many recommended steps but there are three principal elements
Preprocedure verification
Site marking
Time out prior to incision
Facts about the Universal Protocol. Oakbrook Terrace, IL: The Joint Commission; 2014.

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
DeVine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site surgery: a systematic review. Spine. 2010;35:S28-S36.

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
DeVine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site surgery: a systematic review. Spine. 2010;35:S28-S36.

14. There appear to be four errors that resulted in this sentinel event:
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

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

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

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
Sign, Mark & X-Ray: Prevention of Wrong-Site Spinal Surgery. Washington, DC: North American Spine Society; Available at

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

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

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.