Despite their designation in the medical profession as “never events,” wrong-site surgeries still occur in the United States. These mistakes are usually rare, only occurring once in every 100,000 surgeries performed, on average. A review of 138 studies published last year in JAMA Surgery found that one of the most frequent contributing factors is inadequate communication among members of the surgical team.

As with every averaged figure, there are sure to be outliers on both sides. In one extreme example, Genesis Health Group, a health network in the Midwest, had four wrong-site surgeries within a period of just 40 days at the end of last year. The organization indicated that these mistakes may have been due to a failure to properly perform a safety procedure called a “Time Out” prior to beginning the surgery.

This protocol requires all members of the surgical team to confirm the patient, surgical procedure, and site before surgery begins. Genesis itself found various issues with the Time Out procedure, including distractions to the medical professionals, obstruction of the marked surgery site prior to the inspection, and supervision of the Time Out by a nurse rather than the surgeon.

Fortunately, none of these mistakes resulted in the death or serious injury of a patient. The health network’s plan to avoid mistakes like these in the future includes requirements for full team participation in Time Outs, visible surgical site markings, and in-person audits of the procedure. Upon review of this plan, state inspectors from a division of the Department of Health and Human Services determined that it would return Genesis to compliance with federal regulations.

Sources:

[Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review of Surgical Never Events](http://archsurg.jamanetwork.com/article.aspx?articleid=2301000)

[TV-6 Investigates: Genesis has 4 wrong-site surgeries in 40 days](http://kwqc.com/2016/03/03/tv-6-investigates-genesis-has-4-wrong-site-surgeries-in-40-days/)