Waking up from surgery to discover that the wrong leg was amputated or that the wrong level of your spine was operated on sounds like a nightmare. Tragically, such wrong-site, wrong-procedure or wrong-patient surgical mistakes are a part of reality.
The Joint Commission, who accredits and certifies American health organizations, estimates that incorrect procedures still happen about 40 times a week across the U.S.
In 2004, the Joint Commission mandated a three-step protocol to keep these tragic errors from continuing. Despite the universal protocol, however, new evidence suggests that incorrect surgical procedures are actually on the rise. In a study recently published in the Archives of Surgery, Colorado physicians self-reported 27,370 adverse events between 2002 and 2008 – 132 of which were wrong-patient or wrong-site procedures. And these numbers include only the events that were voluntarily reported.
The three-step universal protocol established in 2004 requires health care professionals to:
- Conduct a pre-procedure verification process
- Mark the procedure site
- Perform a “timeout” discussion as a final check before the beginning the procedure
Patient safety experts believe the problem isn’t with the three-steps, but rather with a failure to follow it every time. Studies have revealed that busy physicians and overloaded hospitals may rush through the checks or the operating surgeon may not even be present during the timeout discussion.
Former chief patient safety officer for the Veterans Health Administration Dr. James Bagian said, “I’m not aware of a case we’ve ever had where the procedures were followed correctly and we still had an incorrect surgery.” Dr. Bagian also noted that in cases of wrong-site or wrong-patient incidents, healthcare professionals usually believed they had properly executed the protocol, “if we gave the people involved a lie-detector test they’d tell you they did it all correctly, and the lie detector would indicate they were telling the truth. They believed that they had done everything correctly but they actually did not. This represents a lack of diligence.”
Lack of diligence – and the failure to comply with protocols – along with poor communication and lack of physician leadership are the main reasons that wrong-procedure surgical errors continue to occur.
Zero Tolerance Needed For Patient Safety
Such increase in medical negligence is alarming to most medical professionals. A surgical director at the Denver Health Medical Center, Dr. Philip F. Stahel, noted, “In aviation safety, we don’t discuss whether we’ll tolerate 50 jumbo jets crashing a year versus 100. We want zero tolerance. The same is true of wrong-site and wrong-patient surgery, because every case is a pure catastrophe for the patient involved.”
Since January of 2009, Medicare and Medicaid refuse to cover procedures performed on the incorrect patient or incorrect site.