Operating on the wrong organ or body part — or on the wrong person — is a clear case of surgical malpractice. But a recent study of wrong-site and wrong-patient procedures showed an alarming trend: the rate of these “never events” continues to rise despite mandatory safety rules put into place in 2004 called the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The study, published in the October issue of Archives of Surgery, looked at negligent misidentification during surgeries and other invasive procedures. It found that reports of wrong-person and wrong-site events actually peaked after the Universal Protocol was implemented.
The reason? Doctor and hospital negligence. In 72 percent of wrong-site surgeries, the protocol was not performed — often because of a lack of physician leadership.
Zero Tolerance Necessary for Wrong-Site, Wrong-Patient Procedures
The Universal Protocol was developed by the Joint Commission, a non-profit organization that certifies health care organizations. The protocol itself is simple and common-sense:
Nevertheless, some health care professionals rush through the checks, and some surgeons aren’t even in the operating room for the time-out discussion. Although following the Universal Protocol takes a few minutes, there is never an excuse for surgical errors caused by rushing an invasive procedure.
“In aviation safety, we don’t discuss whether we’ll tolerate 50 jumbo jets crashing a year versus 100,” says Philip F. Stahel, MD, PhD, the study’s lead author. “We want zero tolerance. The same is true of wrong-site and wrong-patient surgery, because every case is a pure catastrophe for the patient involved.”
“This is where top-down leadership comes in,” says Dr. LaMar McGinnis of the American College of Surgeons. “The chief of surgery needs to make a stand that this will be done — no ifs, ands or buts.”
Wrong-Site and Wrong-Person Procedures Not Limited to Surgeries
Medical malpractice is not limited to surgeons, and wrong-site and wrong-patient errors are not limited to the operating room. According to the study, 25 percent of wrong-patient procedures involved internists. 32 percent of all of the incorrect procedures were non-surgical procedures involving radiology errors, emergency room errors or even negligent dermatology.
In fact, the single death reported in the study occurred when a chest tube was placed on the incorrect side, causing acute respiratory failure.
“What we have unearthed is evidence that wrong-site and wrong-patient events are certainly of concern for nonsurgical specialties,” says study co-author Dr. Michael S. Victoroff. “The family doctors, the pediatricians, the dermatologists, the endocrinologists, nurses, pharmacies — all kinds of people are getting this wrong sometimes.”
“Slow down — pause,” says Victoroff. “Stop what you’re doing. Recalibrate. Step back. Change the field of focus. Look around. Take a breath.”
“It’s…a time to have reverence for what’s about to happen,” adds McGinnis. “You’re entering hallowed ground when you’re entering someone’s body.”
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