Sources: Archives of Surgery 2010;145:978-984; MedScape
Hospitals continue to experience wrong-site and wrong-patient surgeries, which are more common than the medical community might care to admit. Investigators have found that clinicians in both surgical and nonsurgical disciplines share equal responsibility for the unacceptable errors.
Dr. Stahel and colleagues in Colorado and at the Geisinger Medical Center in Danville, Pennsylvania, retrospectively reviewed data on 27,370 adverse outcomes reported by physicians to the Colorado Physicians Insurance Company. Their goal was to determine the frequency, cause, and outcomes of wrong-site, wrong-patient procedures after widespread adoption of the Universal Protocol proposed by the Joint Commission on Accreditation of Healthcare Organizations. The study revealed 25 wrong-patient and 107 wrong-site procedures during a 6.5-year period. The wrong-patient procedures included 5 cases of significant harm, including 3 unnecessary prostatectomies resulting from a mix-up in pathology samples. Wrong-site procedures included an errantly placed chest tube that lead to the patient’s death from pulmonary decompensation, report Philip F. Stahel, MD, from the departments of Orthopaedic Surgery and Neurosurgery at the Denver Health Medical Center, University of Colorado School of Medicine, and colleagues.
The biggest surprise in the study? “Nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures.” How’s that? Inadequate planning of procedures and the lack of adherence to the time-out concept (where the operating team literally takes a “time out” to make sure they have the right patient, the right procedure, and the right portion of the anatomy -before continuing) are the major determinants of adverse outcome.
The actual incidence of wrong-site surgery is likely to be higher than that determined by the authors, who had to rely on physician self-report of errors to a database that was not anonymous, notes Martin A. Makary, MD, MPH, from the Department of Surgery at Johns Hopkins University in Baltimore, Maryland, in an accompanying editorial. “This study alerts us, yet again, to the alarming problem of preventable errors — a systems issue that should have been engineered from surgical care long ago. Instead, we are only now beginning to realize the magnitude of the problem,” Dr. Makary writes.
Errors in diagnosis were responsible for 14 of the 25 wrong-patient mistakes (56%) and for 13 of the wrong-site failures (12.1%). Errors of communication occurred in all of the wrong-patient cases and in nearly half of the wrong-site cases. In contrast, errors in judgment, primarily inadequate procedure planning, occurred in the large majority (85%) of wrong-site cases, but in only 8% of the wrong-patient errors. Other causes for mistakes included wrong indications for a procedure, failure to take a “time-out” before a procedure (in 72% of wrong-site cases), and other system-related issues.
Only 36% of wrong-patient cases and 2.8% of wrong-site cases caused no harm, the authors noted. The authors call for universal adoption of the Universal Protocol, which was recently folded into broader National Patient Safety Goals issued by the joint commission. The Universal Protocol must be expanded to nonsurgical specialties to achieve a zero-tolerance philosophy for these preventable incidents,” the authors write.
The Lewis Law Firm handles cases of physician and hospital malpractice causing injury and death in Philadelphia and New Jersey. If you or a loved one were the vitim of wrong-site or wrong surgery, contact the Lewis Law Firm for a FREE consultation today.