You would think that easy mistakes, like surgery on the wrong part of the body or wrong patient, could be easily eliminated. Well it can. But it hasn’t.
An article this week in Kaiser Health News highlights the continuing problem (Effort To End Surgeries On Wrong Patient Or Body Part Falters). Seven years after universal protocols were instituted by the Joint Commission on Accreditation, “some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse.” These were some of the facts:
Based on state data, Joint Commission officials estimate that wrong-site surgery occurs 40 times a week in U.S. hospitals and clinics. Last year 93 cases were reported to the accrediting organization, compared with 49 in 2004. Reporting to the commission is voluntary and confidential — to encourage doctors and hospitals to come forward and to make improvements, officials say. About half the states, including Virginia, do not require reporting. In two states that track and intensively study these errors, 48 cases were reported in Minnesota last year, up from 44 in 2009; Pennsylvania has averaged about 64 cases for the past few years.
Medical workers continue to mix up left and right sides, view x-rays backwards, fail to take timeouts to insure they have the right patient and right surgery, and make other routine errors. There is also this study cited by the article:
Reported cases are “clearly the tip of the iceberg,” said Philip F. Stahel, director of orthopedic surgery at Denver Health Medical Center.
Stahel was lead author of a 2010 study of 132 wrong-site and wrong-patient cases reported by doctors to a large malpractice insurer in Colorado between 2002 and 2008, one-third of which resulted in death or serious injury. Among them were three men who underwent prostate cancer surgery although they were cancer-free. In 72 percent of cases there was no timeout.
There is much more in the article, and I encourage others to read it, but there something else buried at the end, which deals with a doctor apologizing for doing a carpal tunnel surgery when he was supposed to do a trigger finger release. He confessed to the patient, then did the proper surgery. The hospital paid out a small settlement and there was no litigation. And that is likely because, as one book argues saying “I’m sorry” works, which happens to be in tune with my own observations of human behavior.