I’ve written before on this web site about the dangers of “wrong-site” surgery. It should never happen, and yet continues to be a risk at almost every hospital. The Associated Press reported yesterday that for the fifth time in the last two years, the wrong side of a patient’s body was operated on in a Lifespan Hospital. Amongst Lifespan’s hospitals are Rhode Island Hospital and Hasbro Children’s Hospital, where the latest wrong-site error took place. This time, the surgery was on the patient’s mouth; apparently, the harm was not severe.

The means to prevent of wrong-site surgery are simple and cheap, but must be followed without exception if they are to be successful. JCAHO, the Joint Commission on Accreditation of Healthcare Organizations, has promulgated universal standards to prevent wrong-site surgeries. Uniformity, repetition, and no exceptions are key amongst prevention of the potentially serious surgical error. JCAHO recommends that the responsible health professionals verify the correct patient, correct site, and the correct procedure, not once, but five times: (1) when the procedure is scheduled; (2) at preadmission testing and assessment; (3) at the time of admission to the facility; (4) before the patient leaves the pre-procedure area; and (5) whenever responsibility for the patient’s care is transferred to another member of the medical team. Moreover, whenever possible, the patient should be involved in verification while awake and aware.

In addition to enacting universal protocols for healthcare professionals, JCAHO advises patients to insist that precautions be taken to prevent surgery on the wrong site of their body. According to JCAHO, patients should ask that the surgical site be marked with a permanent marker, and that they be involved in the marking process. Patients should also ask questions and voice any concerns they may have. They need not and should not, view themselves as passive recipients of medical care. The latest version of the JCAHO universal protocol took effect in January 2009. The concepts are not new. It is no exaggeration to say that any wrong-site surgery is almost certainly due to negligence – avoidable medical error.