TY - JOUR T1 - The egocentric surgeon or the roots of wrong side surgery JF - Quality and Safety in Health Care JO - Qual Saf Health Care SP - 396 LP - 400 DO - 10.1136/qshc.2007.023564 VL - 17 IS - 6 AU - John W Senders AU - Regine Kanzki Y1 - 2008/12/01 UR - http://qualitysafety.bmj.com/content/17/6/396.abstract N2 - “Oh wad some power the giftie gie usTo see the world as our patient sees it!It wad frae monie a blunder free us, And foolish notion.”(With apologies to R Burns)A wrong site procedure is an event in which any medical (frequently surgical) procedure is executed on the wrong body part, or on the correctly named body part but on the wrong side of a patient’s body. If the procedure is surgery then the event is a wrong site surgery or a wrong side surgery. Wrong side surgery is generally considered to be a subset of wrong site surgery. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) reviewed 15 reported cases of wrong side surgery in a “Sentinel Event Alert” of August 1988. The problem has gained more attention since that time. In 2003, JCAHO promulgated a “Universal protocol for eliminating wrong site, wrong procedure, wrong person surgery”. Our own interest arose (see Acknowledgement) from a chance event.There are no reliable probabilities of various kinds of wrong side and wrong site surgery, because of both poor numerators (number of events) and poor denominators (opportunities for events). JCAHO classifies wrong side surgery as “sentinel events” and accumulates statistics. From 2000 to 2005 there were 3044 sentinel events (categorised in table 1). Wrong site surgery events are near the top of the list and we may assume that about 80% of them were wrong side surgery events (see tables 2 and 3).View this table:In this windowIn a new windowTable 1 Classification of 3044 sentinel events reviewed by JCAHO, January 1995 through March 20051View this table:In this windowIn a new windowTable 2 Types of wrong surgery*View this table:In this windowIn a new windowTable 3 Surgery error rates in the Veterans Administration system3As both JCAHO and the Veterans Administration (VA) system show, most wrong site surgery events are wrong side surgeries. The statistics offered are similar. JCAHO reports a wrong side/wrong site surgery ratio of 0.76 (0.59/(0.59+0.19)), and the VA ratio is 0.86 (0.44/(0.44+0.07)). Ericson4 of Washington University in St Louis estimates that … ER -