Surgical Mistakes Still A Problem, Study Finds

Last year we wrote about at least six botched surgeries that took place in 2007 in one hospital alone. A emerging study says that <"">surgical mistakes continue, wrote Business Week

According to Business Week, mistakes include operations taking place on the wrong body part to surgeries being performed on the wrong patients. In 2004, the Joint Commission, implemented a protocol for all “hospitals, ambulatory care facilities, and office-based surgical facilities,” said Business Week, which noted that while the steps are generally followed, errors continue.

“What is shocking about the data is that each and every one of those wrong-site, wrong-patient errors is really an event that should never happen,” said study author Dr. Philip F. Stahel, quoted Business Week. Dr. Stahel is a visiting associate professor at the University of Colorado School of Medicine in Denver. “These happen much more frequently than we think. This is just the tip of the iceberg,” he said. “Introducing the universal protocols have not reduced the frequency of these events,” he added reported Business Week. The report appears in October’s Archives of Surgery.

The universal three-step protocol mandates that: “A pre-procedure verification, marking the correct surgical site, and a “time-out” for the operating staff just before the surgery,” wrote Business Week.

Stahel’s team compiled data on surgical errors from medical liability insurance firm based in Colorado, said Business Week. Physicians reported 27,370 adverse events that occurred between January 2002 and June 2008, which included 25 so-called wrong-patient and 107 wrong-site operations, wrote Business Week. The errors included five patients who underwent unnecessary surgery and 38 patients who underwent wrong-site operations and who were also seriously harmed; one of the patients who endured a wrong-site procedure died, noted Business Week.

The team endeavored to understand the cause of these errors and found that, in most cases—about 56 percent—diagnostic errors were to blame in operations conducted on the wrong patient; 100 percent were due to, said the team, “poor communication,” which included a case in which the wrong child was brought into the operating room, said Business Week.

Wrong body part surgeries involved 85 percent in which judgment errors occurred and 72 percent in which the mandated “time-out” was not conducted, said Business Week. The time-out involves operating staff ensuring they have the right person and that all staff members know what body part is being worked on, explained Business Week.

“Once we were fully responsible for our actions—now we hide behind a safety system that should cover the problem. The time-out is performed, but people are not mentally involved—the system alone cannot protect you from wrong-site surgery,” he said, according to Business Week. The researchers blamed the medical profession.

Stahel said doctors need to assume more responsibility for their mistakes. “We are going from a culture of blame to a culture of system safety, and we should move on to a culture of patient safety and accountability,” he said, wrote Business Week.

Rhode Island Hospital was blamed for at least six botched surgeries in 2007, including wrong-site surgeries five times.

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