Medical Errors

Wrong-Site Surgery

Tuesday, October 3, 2006

The Problem Surgery on the wrong body part -- or the wrong patient -- is widely regarded as the one of the most egregious errors in medicine. In recent years the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as some physician and patient advocacy groups have tried to eliminate such errors by having doctors or patients -- or both -- mark the correct site or verify the procedure beforehand.

Now a study in the September issue of the Archives of Surgery reports that the problem may be 20 times more common than previously thought and that prevention efforts may be inadequate. Using four separate databases including the federal National Practitioner Data Bank, a repository of malpractice payments and disciplinary actions, physicians Samuel C. Seiden and Paul Barach estimate that wrong-site surgery occurs between 1,300 and 2,700 times a year in the United States.

Why It Happens In 2004 JCAHO required that hospital staffs take an operating room "timeout" to verify the patient's identity, confirm the procedure to be performed and ensure that all needed equipment was present. But because the commission does not require reporting or investigation of wrong-site errors, the authors say, it's impossible to tell if the new policy is working.

One unidentified health-care system, they report, that had a similar policy in place experienced 14 wrong-site cases between January 2003 and June 2004. Reported cases include a patient who had his sole functioning kidney removed and a stroke survivor who was supposed to undergo circumcision but had his testicles removed instead. Both patients had verbally verified the procedures beforehand.

What to Do Reporting of wrong-site procedures should be mandatory, which would enable careful analysis of cases to prevent future occurrences, Seiden and Barach say. Officials should use better systems, including bar-coding to identify patients, and patients should be encouraged to verify the site and their identities -- but only "in conjunction with built-in redundancies."

-- Sandra G. Boodman


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