Wrong-site surgery is a devastating outcome that affects both the patient and the surgeon. It is not uncommon. In 1998, Lander and Rowan surveyed 166 practising New Zealand orthopaedic surgeons with reference to wrong-site surgery. They presented their findings at the New Zealand Orthopaedic Association Annual Scientific Meeting in Wellington (1999, unpublished data). They found that 38% had experienced at least one case of wrong-site surgery in their careers. In 10% of cases a major contributing factor was the patient misinforming the surgeon regarding the surgical site.

The New Zealand Orthopaedic Association (NZOA) established guidelines to address the issue of wrong-site surgery following a highly publicised case in New Zealand (Surgical Site Marking Policy, NZOA 2000, unpublished advice to members). The guidelines recommend that the surgeon pre-operatively marks and initials the surgical site with a permanent marker, and that the mark must still be visible when the patient is draped. Marking should be performed before pre-medication. The pre-operative nurse then checks that the mark is present and corresponds with the consent and booking forms. The patient is not admitted to the operating room until the site is marked and, finally, surgery does not commence until the surgeon and scrub nurse verbally verify with the circulating nurse that the mark is visible and correlates with the consent form. This verification is then recorded.

We report on two cases from Christchurch that nearly or did result in wrong-site surgery being performed, despite pre-operative marking of the limb. In both of these cases the patient wrongly identified the surgical site for marking. The cases demonstrate deficiencies in pre-operative checks that are not uncommon amongst practising New Zealand orthopaedic surgeons and highlight the risk of the patient volunteering incorrect information as a contributing factor in wrong-site surgery.

A 68-year-old, otherwise-well female was undergoing a trigger-finger release of her little finger under general anaesthetic in a private hospital. The clinic letter specified the side and digit to be operated on, but neither the consent form nor the operating list specified the digit. A pre-medication had not been administered. The patient was approached by the surgeon prior to entering the operating room and asked which finger was to be operated on. She identified the ring finger, which was marked appropriately with a permanent marker. The surgery was performed on the incorrect digit. It was unclear as to the reason the patient should identify the finger incorrectly other than that she was very nervous.

A 20-year-old, otherwise-well male was undergoing a Bankart repair of his shoulder for anterior instability in a private hospital. The side of surgery had been documented appropriately on the clinic letter, the booking and consent forms, and the operating list. The patient had received no pre-medication. Prior to entering the operating room the patient was approached by the surgeon and asked which shoulder was to be operated on. He identified the incorrect limb, which was marked with a permanent marking pen, however the site was not checked against the patient’s consent form. On entering the operating room the surgeon re-approached the patient to confirm the side of surgery. The patient then informed the surgeon that the incorrect side had been marked. He had been mistaken in thinking that his arm was being marked for a drip, despite the surgeon asking him at the time to identify the shoulder to be operated on. Wrong-site surgery was avoided.

In both of these cases there was a failure to follow all of the pre-operative checks as outlined in the NZOA guidelines. There was no correlation with the consent form prior to entering the operating room and no verbal confirmation that the surgical site was correct prior to commencing surgery. The consent form had not specified the exact surgical site. Despite pre-operative marking of the limb and confirmation of the surgical site with the patient, wrong-site surgery occurred. This demonstrates that pre-operative marking of the limb alone does not safeguard against wrong-site surgery.

We recommend that all practising surgeons familiarise themselves with all of the pre-operative checks recommended by the NZOA, including correlation of the surgical site with the consent form and verbal verification of the site prior to commencing surgery. These practices should be adopted in all operating rooms. Surgeons should also recognise the significance of incorrect information from patients as a contributing factor in wrong-site surgery.

Author information: Richard C Peterson, Orthopaedic Registrar, Department of Orthopaedic Surgery, Christchurch Hospital, Christchurch

Correspondence: Dr Richard C Peterson, Department of Orthopaedic Surgery, Southland Base Hospital, P O Box 828, Invercargill. Fax: (03) 214 7276; email: richard.peterson@sdhb.govt.nz