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Surgical Mishaps Still a Problem

According to a recent study by the Joint Commission, hospital errors pertaining to wrong patient and wrong site surgeries are still a problem, even 6 years after the agency established its Universal Protocol for hospitals, ambulatory care facilities and office based surgical centers to comply with. 

Study author Dr. Philip F. Stahel, visiting associate professor at the University of Colorado School of Medicine in Denver, led a team of researchers who gathered data from a company that provides liability insurance for 6,000 physicians in the state of Colorado.  The team looked at surgical records from January 2002 to June 2008.

Per the study abstract, statistics were generated to provide information on the characteristics of reporting physicians, the number of adverse events per year, and the “root causes and occurrence related patient outcomes.”

During that time period, 23,370 self reported adverse events were reported; of those, 25 were wrong patient surgeries and 107 were wrong site procedures.  Five of the wrong patient victims and 38 of those who had wrong site surgeries were “significantly harmed.”

According to Stahel’s team, diagnostic errors were responsible for 56% of wrong patient surgeries, while 100% were due to communication errors, such as calling the wrong patient in to surgery.

Conversely, 86% of wrong site procedures were due to judgment errors, while 72% were the result of not following the “time-out” rule outlined in the universal protocol.  “Time out” refers to all attending medical personnel making sure they have the right patient and that they are all fully aware of what part of the body they will be operating on.

Interestingly, 24% of wrong patient surgeries were performed by internal medicine specialists.  Those specializing in family practice, pathology, urology, ob-gyn and pediatrics each accounted for 8% of such surgeries.

In the abstract conclusion, the team states:  “Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.”

The Joint Commission’s Board of Commissioners approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery in 2003.