Report Finds Rise in ‘Wrong-Site’ Surgery Errors
The incidence of surgery in which a doctor operates on the wrong part of a patient's body or on the wrong patient appears to be increasing, according to a report released yesterday by the Joint Commission on Accreditation of Healthcare Organizations. The Washington Post reports that the report found that cases of "wrong-site" surgery have risen from 16 in 1998 to 58 this year, including 11 in the past month. Although the report found that some of the cases had "serious consequences," including death, most "produced no permanent disability." The report attributed the problem in part to a trend toward "high-volume, same-day surgery" (Brown, Washington Post, 12/6). Most cases resulted from a "breakdown in communication" between doctors, patients and patients' families, the report found (Tanner, AP/St. Louis Post-Dispatch, 12/5). "People are busy, and patients are being put to sleep before there is an opportunity to verify who the patient is, what procedure is going to be performed and on what site," JCAHO President Dennis O'Leary said (Washington Pose, 12/6). JCAHO's analysis of 126 cases of surgical errors found that 76% resulted from operations on the wrong body part, 13% from operations on the wrong patient and 11% from the wrong surgical procedure (AP/St. Louis Post-Dispatch, 12/5). The report found that about 40% of the cases appeared in orthopedic surgery, 20% in general surgery, 14% in neurosurgery and 11% in urology. About 58% of the events appeared in outpatient or ambulatory surgical centers, 29% in standard hospital operating rooms and 13% in emergency rooms or intensive care units, the report found (Washington Post, 12/6).
The JCAHO report recommended that patients "insist that the area to be cut is marked with a pen, preferably by their surgeon" (USA Today, 12/6). "This is an opportunity for patients to actively participate to ensure their own safety," O'Leary said (Lasalandra, Boston Herald, 12/6). He added, "Patients must not feel intimidated. They must feel free to ask questions" (Anstett, Detroit Free Press, 12/6). The report also recommended that doctors consider a "time-out" in the operating room to ensure that they have the correct surgery site, patient and procedure (AP/St. Louis Post-Dispatch, 12/6). In addition, the report recommended that doctors compare scheduled procedures with medical records and tests, ask members of the surgical team to identify the patient and surgery site after they arrive in the operating room and establish hospital systems to monitor surgery guidelines (Detroit Free Press, 12/6). "The know-how to create systems that prevent wrong site surgeries has existed for years, yet the number of errors has not decreased. Even one wrong-site surgery is too many," O'Leary said (JCAHO release, 12/5). JCAHO, which accredits 80% of the nation's hospitals, said that the group will begin "close monitoring" of surgical errors in hospitals early next year. Hospitals that do not comply with patient safety procedures outlined by the group could lose their accreditation (Boston Herald, 12/6). To view the report, go to http://www.jcaho.org/edu_pub/sealert/sea24.html.