Surgery on wrong-patients or wrong body part still frequent

The Chiropractic journal – April 2011

Surgery on wrong-patients or wrong body part still frequent

A study published in the Archives of Surgery (a JAMA publication) revealed that, despite warnings and safety regulations, surgeons frequently perform operations on the wrong body part or even the wrong patient.

A team of researchers headed by Philip F. Stahel, MD, PhD, director of the Dept. of Orthopedic Surgery at the Denver Health Medical Center, studied surgical cases dating from Jan 1, 2002, to June 1, 2008, reported by the Colorado Physician Insurance Co. Even out of this relatively small sample, there were a total of 25 wrong-patient and 107 wrong-site procedures.

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%). Wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a “time-out” (72.0%).

The problem occurs both in and outside the operating room. A quarter of wrong-patient cases reported in the study involved internists, and 32% of all the incorrect procedures involved nonsurgical specialists such as radiologists and dermatologists. The one death reported was due to a chest tube being placed on the incorrect side, causing acute respiratory failure.

The “time-out” is a three-step protocol instituted by the AMA Joint Commission in 2004 to prevent these types of mistakes. It required physicians and other health professionals to perform a pre-procedure verification process, mark the correct site for the procedure and conduct a “time-out” discussion as a final check before the procedure begins.

The protocol has been an obvious failure, particularly in light of the fact that the number of wrong-patient and wrong-site procedure reports actually increased since it went into effect.

The researchers appeared as surprised as everyone else. In its Nov. 1, 2010 report on the study, the AMAnews quoted Dr. Stahel as saying: “Everyone was under the assumption that when the so-called universal protocol was implemented in 2004, it would lead to a decrease in these ‘never events.’ Not only did they not decrease, they increased. In the first few years, the universal protocol did not prevent these never events from happening.”

According to the same AMAnews report, written by Kevin B. O’Reilly, “the commission estimates that incorrect procedures happen about 40 times a week in the U.S.”


Sources: “Wrong-patient, wrong-site procedures persist despite safety protocol,” by Kevin B. O’Reilly, Nov. 1, 2010. AMAnews.

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