Wrong-site Surgeries Still Persist

November 25, 2011

Wrong-site Surgeries Still Persist

As the nation moves toward health care reform, and reducing the risk of surgery-related injuries and complications, another public health concern looms. For people like a Virginia woman who recently underwent surgery to remove a benign tumor only to find that the surgeon had operated on the wrong shoulder, the issue is very real. Wrong-site surgery is a significant medical error and a recent Health Affairs study has brought to light how serious the issue has become in American hospitals.

In a recent study published in Health Affairs, a leading journal of health policy, researchers found that the methods in place to track and prevent adverse hospital events, date poorly, and miss 90 percent of adverse events. Wrong-site surgeries, which are considered sentinel events, or events that are an unexpected occurrence involving death or serious physical or psychological injury, are occurring with increased regularity.

Specifically on wrong-site and wrong-patient surgeries, Colorado researchers published findings in the Archives of Surgery last year. Lead by surgeon Phillip Stahel of the Denver Health Medical Center, these researchers analyzed over 27,370 patient records and discovered that doctors in Colorado operated on the wrong body part in 107 patients and on the wrong patient at least 25 times over a six year period. Wrong-patient and wrong-site procedures represented about 0.5 percent of all medical mistakes analyzed.

Based on state data, The Joint Commission Board of Commissioners, an organization which accredits and certifies more than 19,000 health care organizations and programs in the nation, estimates that wrong-site surgeries occur approximately 40 times a week in U.S. hospitals and clinics. In 2010, nearly 100 cases were reported to the Joint Commission as compared to nearly 57 a few years ago.

In 2003, The Joint Commission, noting wrong-site surgeries and procedures as a problem, developed the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. Last year, its protocol was revised to address the causes and possible preventions for wrong-site errors. Still, these preventable sentinel events continue to occur with sometimes fatal results.

Preventing wrong-site surgery, while seemingly simple on the surface, is more complicated than previously thought. Hospitals have to modify their practice cultures and procedures, which may require the use of surgery checklists, such as SURPASS, and to follow standardized team procedures. Until they do, patient safety cannot be guaranteed.

Article provided by Thomas J. Tomazin, P.C.
Visit us at http://www.tomazinlaw.com