Surgery on Wrong Patients, Surgical Sites Persists, Study
MONDAY, Oct. 18 (HealthDay News) -- Patients undergoing surgery
still risk falling victim to stunning medical mistakes, ranging
from an operation on the wrong surgical site to undergoing surgery
intended for another patient, a new study finds.
To try to curb the rate of surgical errors, the Joint Commission
in 2004 introduced a universal protocol for all hospitals,
ambulatory care facilities and office-based surgical facilities to
follow. However, even though these steps have largely been adopted,
errors continue to happen, the researchers reported.
"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, 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."
The universal protocol requires three critical steps: a
pre-procedure verification, marking the correct surgical site, and
a "time-out" for the operating stuff just before the surgery.
The report is published in the October issue of the
Archives of Surgery.
For the study, Stahel's team collected data on surgical errors
from a company that provides liability insurance to 6,000 doctors
In the database, doctors reported 27,370 adverse events that
happened between January 2002 and June 2008. Among these, the
researchers identified 25 wrong-patient and 107 wrong-site
Of these, five patients who received unnecessary surgery and 38
who received wrong-site operations were significantly harmed, the
researchers found. In addition, one patient who had a wrong-site
In looking for the reasons for these mistakes, Stahel's group
found diagnostic errors accounted for 56 percent of the operations
on the wrong patient, and 100 percent -- including one in which the
wrong child was called to the operating room -- were due to poor
Among operations on the wrong part of the body, 85 percent were
due to errors in judgment and 72 percent were due to not performing
a "time-out" as required by the universal protocol. Time-out is a
common occurrence before an operation begins, when all those in the
operating room check that they have the right patient and that they
know what part of the body they are operating on.
But a safety system alone cannot solve the problem, Stahel
"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.
The blame for these mistakes falls across the medical
profession, the researchers noted. The groups most frequently
involved in operations on the wrong patient were internal medicine
specialists, who were responsible for 24 percent of such mistakes,
and clinicians involved in family or general medicine, pathology,
urology, obstetrics-gynecology, and pediatrics, who were each
responsible for 8 percent, according to the study.
The study also found that specialists in orthopedic surgery were
responsible for 22.4 percent of the operations on the wrong
surgical site, general surgeons for 16.8 percent, and
anesthesiologists for 12.1 percent.
Stahel said doctors should take more personal responsibility for
their errors. "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.
Dr. Martin A. Makary, an associate professor of surgery at Johns
Hopkins University and author of an accompanying journal editorial,
said that "a simple checklist does not solve the problem; it's not
"The culture has to change to promote people speaking up when they see a safety concern and promote good teamwork," he said.
Makary noted that in many cases the people in the operating room
don't know each other and don't even know each other's names. In
addition, the medical culture places doctors above nurses and other
"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 said.
Makary said that culture needs to change.
"By cutting through that culture and preserving what's good about the hierarchy -- that is, one person needs to make quick decisions, but getting rid of the intimidation, it actually improves safety," he said.
Meanwhile, a study in the October issue of the
Archives of Otolaryngology--Head & Neck Surgery, showed that a questionnaire filled out by patients before surgery could help identify patients at risk for complications.
In this study, people prone to obstructive sleep apnea who were
found through the questionnaire appeared to have an increased risk
of heart, lung and other complications following elective surgery,
Dr. Tajender S. Vasu, and colleagues from Thomas Jefferson
University Hospital in Philadelphia, concluded that "most patients
with obstructive sleep apnea syndrome have undiagnosed conditions
and are almost certainly at risk in the perioperative setting. The
STOP-BANG questionnaire is a convenient and useful screening tool
that appears to reliably identify patients who are at increased
risk for postoperative complications."
For more information on patient safety, visit the
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