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Revista Española de Cirugía Ortopédica y Traumatología (English Edition)
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Inicio Revista Española de Cirugía Ortopédica y Traumatología (English Edition) Wrong site surgery
Información de la revista
Vol. 53. Núm. 5.
Páginas 332-339 (septiembre - octubre 2009)
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Vol. 53. Núm. 5.
Páginas 332-339 (septiembre - octubre 2009)
Review article
Acceso a texto completo
Wrong site surgery
Cirugía en sitio erróneo
Visitas
1655
D. García-Germán Vázqueza,
Autor para correspondencia
diegoggerman@gmail.com

Corresponding author.
, J. Sanz-Martínb, F. Canillas del Reya, J. Sanjurjo-Navarroa
a Department of Orthopedic and Trauma Surgery, San José y Santa Adela Red Cross Hospital, Madrid, Spain
b Asjusa-Letramed Healthcare Law Firm, Madrid, Spain
Este artículo ha recibido
Información del artículo
Abstract

The term “wrong site surgery” refers to surgery carried out on the wrong side, in the wrong anatomical area or in the wrong patient. It can also indicate that the surgical procedure employed was not the one intended. In spite of being a rather neglected topic, wrong site surgery is a fairly usual complication in a surgeon's professional life - orthopaedic surgery being the speciality most at risk. Media reports on this subject undermine the general public's distrust of the health care system, surgeons more often than not having to face serious legal consequences. There are at present several easy-to-apply protocols, among them those proposed by the American Academy of Orthopaedic Surgeons (AAOS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which can help preventing these unfortunate occurrences. They basically consist in checking the patient's details, marking the area to be operated and performing a final run-through just before starting the surgical procedure. It is of essence to introduce such a protocol in our own hospitals, with the support of all parties involved, in order to effectively address this problem.

Keywords:
Wrong site surgery
Surgical error
Wrong side
Universal Protocol
Adverse event
Resumen

El término “cirugía en sitio erróneo” engloba aquella cirugía que es realizada en el lado erróneo, en una zona anatómica errónea, en el paciente erróneo o en la que se realiza un procedimiento diferente al planeado. Pese a estar claramente poco comunicada, es una complicación frecuente en la vida profesional de un cirujano, siendo la cirugía ortopédica la especialidad con mayor riesgo. La repercusión mediática aumenta la descon fianza en el sistema sanitario y las consecuencias legales para el cirujano son la norma. En la actualidad hay varios protocolos, entre ellos los propuestos para evitar esta complicación por la American Academy of Orthopaedic Surgeons (AAOS) y la Joint Comission on Accreditation of Healthcare Organizations (JCAHO), de fácil aplicación. Consisten básicamente en comprobar los datos del paciente, marcar la zona que se va a operar y realizar un “tiempo muerto”, una comprobación final, justo antes de iniciar la cirugía. Es fundamental su implantación en los centros de España, con la colaboración de los diferentes estamentos, para una prevención efectiva de este problema.

Palabras clave:
Cirugía en sitioerróneo
Error quirúrgico
Lado erróneo
Protocolo universal ;Suceso adverso
El Texto completo está disponible en PDF
References
[1.]
Joint Commission on Accreditation on Healthcare Organizations. A follow-up review of wrong site surgery. Sentinel Event Alert. 2001;24:1-3 [consultado 13/6/2008]. Disponible en: http://www.jointcommission.org/SentinelEvents/Sentine lEventAlert/sea_24.htm
[2.]
H.R. Cowell.
Wrong-site surgery.
J Bone Surg Am, 80 (1998), pp. 463
[3.]
E.G. Meimberg, P.J. Stern.
Incidence of wrong-site surgery among hand surgeons.
J Bone Joint Surg Am, 85 (2003), pp. 193-197
[4.]
M.G. Mody, A. Nourbakhsh, D.L. Stahl, M. Gibbs, M. Alfawareh, K.J. Garges.
The prevalence of wrong level surgery among spine surgeons.
[5.]
S.T. Canale.
Wrong-site surgery: Apreventable complication.
Clin Orthop Rel Res, 433 (2005), pp. 26-29
[6.]
S.C. Seiden, P. Barrach.
Wrong side/wrong site, wrong-procedure and wrong patient adverse events. Are they preventable?.
Arch Surg, 141 (2006), pp. 931-939
[7.]
J.R. Clarke, J. Johnston, E.D. Finley.
Getting surgery right.
Ann Surg, 246 (2007), pp. 395-405
[8.]
Levy DA. No defence for wrong-site surgery. AAOS Bull. 1998;46:18 [consultado 13/6/2008]. Disponible en: http://www2.aaos.org/aaos/archives/bulletin/jun98/legalcol.htm
[9.]
A. Furey, C. Stone, R. Martin.
Preoperative signing of the incision site in Canada.
J Bone Joint Surg Am, 84 (2002), pp. 1066-1068
[10.]
Canale TS. OK plan to end wrong-site surgeries. October 1997 Bulletin America Academy of Orthopaedic Surgeons [consultado 14/6/2008]. Disponible en: http://www2.aaos.org/aaos/archives/bulletin/oct97/wrong.htm
[11.]
Wong DA. Surgical marking comes of age. April 2004 Bulletin. America Academy of Orthopaedic Surgeons [consultado 14/6/2008]. Disponible en: http://www2.aaos.org/aaos/archives/bulletin/apr04/feature1.htm
[12.]
Joint Commission on Accreditation on Healthcare Organizations. Facts about the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person SurgeryTM [consultado 14/6/2008]. Disponible en: http://www.jointcommission.org/PatientSafety/UniversalProtocol/up_facts.htm
[13.]
World Health Organization. Patient Safety Solutions [consultado 3/12/2008]. Disponible en: http://www.who.int/patientsafety/solutions/patientsafety/en/index.html
[14.]
T. Bhattacharyya, H. Yeon, M.B. Harris.
The medical-legal aspects of informed consent in orthopaedic surgery.
J Bone Joint Surg Am, 87 (2005), pp. 2395-2400
[15.]
D.L. Perlow, S.M. Perlow.
Letters to the Editor. Incidence of wrongsite surgery among hand surgeons.
J Bone Joint Surg Am, 85 (2003), pp. 1849
[16.]
J.P. Lubicky.
Letters to the Editor. Editorial. Wrong-Site Surgery.
J Bone Joint Surg, 80 (1998), pp. 1398
[17.]
G. Cronen, V. Ringus, G. Single, J. Ryu.
Sterility of surgical site marking.
J Bone Joint Surg Am, 87 (2005), pp. 2193-2195
[18.]
D.B. Cullan, M.D. Wongworawat.
Sterility of the surgical site marking between the ink and the epidermis.
J Am Coll Surg, 205 (2007), pp. 319-321
[19.]
C.W. DiGiovanni, L. Kang, J. Manuel.
Patient compliance in avoiding wrongsite surgery.
J Bone Joint Surg Am, 85 (2003), pp. 815-819
[20.]
M.A. Makary, A. Mukherjee, J.B. Sexton, D. Syin, E. Goodrich, E. Hartmann, et al.
Operating room briefings and wrong-site surgery.
J Am Coll Surg, 204 (2007), pp. 236-243
[21.]
M. Stanton, S. Tong-Ngork, G.A. Liguori, C.R. Edmonds.
A new approach to preanesthetic site verification after 2 cases of wrong site peripheral nerve blocks.
Reg Anesth Pain Med, 33 (2008), pp. 174-177
[22.]
Wong D, Mayer T, Waters W. Prevention of wrong-site surgery: Sign, mark and X-ray (SMaX) [consultado 13/6/2008]. La Grange: North America Spine Society; 2001. Disponible en: http://www.spine.org/Documents/SMaXchecklist.pdf
[23.]
P. León Sanz.
La ética en la práctica. Cuando algo se hace mal: del error médico a la mala praxis.
Trauma Fund MAPFRE, 19 (2008), pp. 138-142
[24.]
Advisory statement. Wrong site surgery. Rosemont, IL. American Academy of Orthopaedic Surgeons; 2003 [consultado 14/6/2008]. Disponible en: http://www.aaos.org/about/papers/advistmt/1015.asp
[25.]
T.F. Dagi, R. Berguer, S. Moore, H.D. Reines.
Preventable errors in the operating room-part 2: Retained foreign objects, sharp injuries and wrong site surgery.
Curr Probl Surg, 44 (2007), pp. 352-381
[26.]
J.A. Martín Pallin.
Riesgo y responsabilidad en cirugía ortopédica y traumatología.
Rev Ortop Traumatol, 47 (2003), pp. 210-223
[27.]
M.R. Kwaan, D.M. Studdert, M.J. Zinner, A.A. Gawande.
Incidence, patterns, and prevention of wrong-site surgery.
Arch Surg, 141 (2006), pp. 353-358
[28.]
The Joint Commission on Accreditation on Healthcare. Organizations Universal Protocol. Spanish Version [citado 3 Dic 2008]. Disponible en: http://www.jointcommission.org/NR/rdonlyres/4DF76231-2CB8-461F-B858-C33E5D895C6D/0/UP_Poster_Spanish. pdf
Copyright © 2009. Sociedad Española de Cirugía Ortopédica y Traumatología (SECOT). All rights reserved
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