October 18, 2010—A report published in the October issue of the Archives of Surgery yields unsettling news concerning the frequency of medical mistakes—particularly with operations conducted on the wrong surgical site and operations performed on the wrong patient.
For the study, a company that provides liability insurance to 6,000 doctors in Colorado collected data on surgical errors between January 2002 and June 2008. Doctors reported 27,370 adverse events that occurred during this time period. The results are summarized as followed:
"A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%).”
These tragic mistakes are classified as “never events,” but the alarming truth is that these medical mishaps are much more frequent than expected. In part, the study was aiming to test the effectiveness of the Universal Protocol enacted by the Joint Commission in 2004 to curb the rate of surgical errors. The protocol requires three imperative steps: a pre-procedure verification, marking the correct surgical site, and a "time-out" for the operating stuff just before the surgery.
In light of the continued frequency of serious medical mistakes, the study suggests that the Universal Protocol should be expanded to include nonsurgical specialties to “promote a zero-tolerance philosophy for these preventable incidents.”
Click HERE to view the entire study.