Wrong-site surgeries and wrong-patient procedures performed by health care providers are so awful and so easily avoidable that they are known as “never events,” because there is never a good reason for them to happen.

The Joint Commission, the organization that accredits hospitals, has been working to implement rules to prevent wrong-patient and wrong-site procedures. Unfortunately, the data shows that more of these surgical errors are taking place, not fewer.

One of the problems with tracking surgical errors is that there is no nationwide data available. Roughly half the states do not require reporting surgical mistakes to the commission. For hospitals in all states, reporting is confidential, in order to encourage medical providers to come clean about surgical errors. Pennsylvania is one of the states that does closely track medical errors. In each of the last two years, Pennsylvania doctors and hospitals reported 64 cases of wrong-site or wrong-patient surgeries.

Nationwide, it is estimated that wrong-site surgery is occurring 40 times every week. As reported previously in this blog, Medicare has already begun to require reporting of wrong-site surgeries and will not pay for them. Medicaid will follow suit next year.

There are two reasons that seem likely to be responsible for the increase: doctors’ self-image, and time pressures motivated by an intense desire to cut costs.

The influence of the time pressure is easier to understand, since many of the measures that are meant to prevent wrong-site surgeries (taking a timeout to make sure everyone agrees on the procedure, taking the time to make sure x-rays have not been flipped over, re-confirming the identity of the patient) take time.

What is perhaps a little harder to understand is how some doctors’ self-image comes into play. But it becomes clearer when one considers that many doctors underestimate their own ability to make all-too-human mistakes. In a hospital setting, there are doctors who vigorously defend their own autonomy, which makes them resistant to following checklists and to consulting lower-ranking health care providers in the operating room.

Some patients are lucky and don’t suffer devastating injuries from wrong-site surgeries, either because the surgery was minor or the mistake was caught early. Pennsylvania medical malpractice attorneys know, however, that many of these surgical errors, such as amputations of the wrong limb, cause irreparable harm. In many cases, patients have no choice but to pursue compensation through medical malpractice lawsuits.

Source: Washington Post “The Pain of Wrong Site Surgery” 6/20/2011