Wrong site wrong patient surgery-inexcusable medical error

Operate on the wrong patient or wrong side of the body? Unthinkable, you say?

According to a new study, surgeons do this 40 times a week! A study of more than 27,370 adverse events self-reported by Colorado physicians was published in the October Archives of Surgery.

The study found that 132 wrong-patient and wrong-site procedures were voluntarily reported to the Colorado Physician Insurance Co. from 2002 to 2008, with peak annual numbers of reports for both categories occurring after the Joint Commission’s protocol was required. There were 25 patients who received someone else’s surgery.

“Everyone was under the assumption that when the so-called universal protocol was implemented in 2004, it would lead to a decrease in these ‘never events,’ ” said study lead author Philip F. Stahel, MD, PhD, director of the Dept. of Orthopedic Surgery at the Denver Health Medical Center. “Not only did they not decrease, they increased. In the first few years, the universal protocol did not prevent these never events from happening.” Read more

Who are the surgeons at biggest risk for performing wrong patient or wrong site surgery? Orthopedic/pediatric, general surgery and neurosurgeons. Not surprisingly, they are a bit defensive about the results of this study.

How do you prevent wrong patient and wrong site surgery? Simple: follow the protocol step by step.

How does this happen, you ask? The Joint Commission looked at the risk factors in its Sentinel Event Alert in August 1998. One factor is production pressure. Move the patient in, operate, move her out, clean the room, move in the next patient.

Emergency surgeries are high risk, as well as patients with unusual physical characteristic, including morbid obesity or physical deformity.

Staff working with unusual equipment or patients having multiple surgeons and procedures are at increased risk.

What can operating room staff do to stop this inexcusable medical error?

1. Correctly identify the patient. One of Med League’s operating room nursing experts worked on a case of a childless woman who got someone else’s tubal ligation. It is notoriously difficult to reverse a tubal ligation. No one identified her before starting surgery.
2. Ask an awake and alert patient to identify the surgical site. My mother carried a sign into the operating room before her right lung wedge resection. Her sign said, “It is my right lung.” One of the OR nurses told her she was cute. She retorted, “No, cautious.” A teenager who needed a left knee surgery wrote on her right knee, “Doctor, if you are looking at this knee, don’t.”
3. Create and use a verification checklist that includes the operative consent and any imaging studies.
4. Obtain oral verification of the patient, surgical site, and procedure in the operating room. Involve everyone, including the surgeon, in the verification. One of Med League’s operating room nursing experts worked on a case which involved a failure to correct identify the site. The patient came into the operating room at change of shift. The incoming staff assumed the outgoing staff had performed the verification process. She received surgery on her right knee instead of her left.
5. Expect to not get paid for surgery performed on the wrong patient or site. CMS and private payors will no longer pay for these errors.
6. Administrators, do not tolerate surgeons who want to rush people through the last and most important safety check in the OR. Leadership is top down. There can be no tolerance for shortcuts.
7. Get out your checkbook. These cases are inexcusable and will not happen if people follow the protocols designed to protect the patient.
   Read more about why healthcare providers do not follow the rules part one and part two.
   This is an overview of a recent article in New England Journal of Medicine about the factors that led a hand surgeon to operate on the wrong site.
   

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