The Agency for Healthcare Research and Quality's March 2015 WebM&M describes a wrong-site surgery in which the patient's suspected cancerous kidney was documented incorrectly, leading to the removal of the wrong kidney when images could not be procured to confirm the procedure. Images of the patient's right kidney, taken at one hospital, showed a suspected renal cell carcinoma. However, documentation located the carcinoma in the patient's left kidney. The hospital where the surgery took place did not have access to the patient's images, only his records, and imaging was not re-obtained. The surgery proceeded without imaging, and the incorrect kidney was removed. When no evidence of cancer was found, the error was realized, and the right kidney (which proved cancerous) was removed. However, the patient "was then dependent on dialysis, and because of the cancer, he was not a candidate for kidney transplant." Commentary on the case highlights four errors: incorrect documentation at the initial hospital, not including images during patient transfer, a lack of preoperative imaging, and not having the images present in the room during the surgery. Interventions that can be used to prevent such an occurrence include the use of the Joint Commission's Universal Protocol and policies requiring the presence of images in the operating room prior to incision.

HRC Recommends: As the commentator states, wrong-site surgery should be preventable with the use of indicators such as imaging, as enforced by the Universal Protocol. Organizations should implement a mechanism to ensure verification and reconciliation of patient information, including a review of any imaging studies obtained, before the start of surgery.