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Procedures on Wrong Sites and Wrong Patients Grow

About one out of every 75,000 surgeries in the U.S. is performed on the wrong body part, or even the wrong patient. One of these surgeries may be taking place right now.

Although this number may sound small at face value, one small study in Colorado shows the magnitude of this important problem. A study of the liability coverage for 6,000 doctors between Jan. 1, 2002, and June 1, 2008 revealed 107 cases of procedures done on the wrong part of a patient’s body, and 25 done on the wrong patient. It was revealed that one patient died after surgery on the wrong lung.

And this is just a sample from one state!

The Joint Commission, which regulates medical professions, introduced a Universal Protocol in 2004. The protocol is designed to reduce medical errors, and it is supposed to be followed by all hospitals and outpatient facilities that perform medical procedures.

The protocol has three parts: a pre-procedure verification, a surgical site marking, and a "time-out" performed immediately before the surgical procedure. During the time outs, members of the surgical team are tasked with confirming three things:  the identification of the patient, the type of procedure, and the procedure site.

Study results revealed that surgical teams apparently hate time outs almost as much as kids do. The lack of performing a time out before starting the surgical procedure was cited as the cause in 72% of mistakes in wrong-site procedures or surgeries. Also, errors in judgment were contributing factors in 85% of wrong-site medical errors.

terms of surgeries or procedures involving the wrong patient, errors in communication were found to be present 100% of the time, and errors in diagnosis contributed to 56% of cases.

The study appears in the October issue of Archives of Surgery.

The researchers noted that a simple protocol is not enough to prevent such mistakes, because the culture of emergency rooms and operating rooms (ORs) must change. Currently, the atmosphere in the OR is very tense and intimidating, they said, due to the staff hierarchy. Many mistakes that could be avoided are not brought to light because most OR staff are intimidated and afraid of the repercussions if they speak up.

Frighteningly enough, the lead researcher said it is a smart idea for patients to ask their surgical teams to have a briefing, and also to mark the spot on their body where surgery will be performed, if appropriate. One hundred percent of these mistakes can be prevented, he said.

It’s a shame that incidents such as surgery on the wrong finger even take place, which is what happened to one patient in what is perhaps the most notorious hospital in the country for wrong-site surgeries. Five people experienced wrong-site surgeries at the Rhode Island Hospital between January, 2007 and the end of 2009. The wrong-finger surgery cost the hospital a $150,000 fine, and it also led the hospital to retrain all surgical staff, and place cameras inside all ORs.

Earlier this month, the same hospital admitted it did not follow proper post-surgery procedures, which caused a piece of a drill bit to be left inside a patient’s skull for two days. Luckily, if you’re traveling to Rhode Island and happen to get sick, it doesn’t take much effort to reach the state border.

Not to scare those of us who will undergo surgery or medical procedures, (which will be sooner than later for most of us), but researchers say non-surgical specialties, such as general or family practice, internal medicine, emergency medicine, and pediatrics, are as much to blame as surgeons when it comes to wrong-site medical mistakes and associated complications.

A patient’s Sharpie might be the most important instrument in any medical facility these days. In addition to pre-surgical body art, it can be used for a name tag too.