Patients who had surgery in Colorado between 2002 and 2008 ran a slight risk of being under the wrong doctor’s knife or having the wrong body part operated on, according to a study in the Annals of Surgery.
Researchers examined 27,370 adverse event reports for that time, looking for so-called “never events” — medical errors that are never supposed to happen, like operating on the wrong patient or body part. There were 25 wrong-patient and 107 wrong-site operations during the six-year span.
Five of the patients who received unnecessary surgery and 38 who received wrong-site operations were significantly harmed, according to the study — including a death following a wrong-site surgery. Diagnostic errors accounted for 56 percent of wrong-patient procedures and 100 percent came down to poor communication.
Eighty-five percent of wrong-site incidents were due to errors in judgment. Failure to perform a “time-out” — part of a universal protocol, designed to double-check the identity of the patient and the operation site, that’s supposed to be observed for every surgery — accounted for nearly three-quarters of the wrong-site events.
“These happen much more frequently than we think. This is just the tip of the iceberg,” study author Dr. Philip Stahel of the University of Colorado School of Medicine told BusinessWeek. “Introducing the universal protocols have not reduced the frequency of these events. … The time-out is performed, but people are not mentally involved — the system alone cannot protect you from wrong-site surgery.”
“A simple checklist does not solve the problem; it’s not that simple,” added Dr. Martin Makary of Johns Hopkins University. “The culture has to change to promote people speaking up when they see a safety concern and promote good teamwork.
“A nurse or a low-level person in the surgical hierarchy may sense that something is not right, but they don’t speak up because they are intimidated by the operating room hierarchy,” he told the magazine.
Here’s a breakdown of the incidence of never events for various specialties:
Specialty | Never event | % |
Internal medicine | wrong patient | 24% |
Family practice | wrong patient | 8% |
General practice | wrong patient | 8% |
Pathology | wrong patient | 8% |
Urology | wrong patient | 8% |
Ob/Gyn | wrong patient | 8% |
Pediatrics | wrong patient | 8% |
Orthopedics | wrong site | 22.4% |
General surgery | wrong site | 16.8% |
Anesthesiology | wrong site | 12.1% |