The Washington Post has recently revealed that according to the Joint Commission Center for Transforming Healthcare 40 wrong-site surgeries happen every week in the United States.
Amputating The Wrong Leg
Mistakes include amputating the wrong leg, operating on the wrong patient or in lay terms, performing the wrong surgery. Surgeon Dennis O’Leary says that wrong site surgery may be prevented by checking things as simple as that the right patient is on the operating table or that an X-ray isn’t flipped….
With the cooperation of 8 hospitals and ambulatory surgery centers, the Commission studied their operating protocols and found that the risk of wrong-site surgeries happening increased with problems within the facilities’ preoperative procedures and scheduling processes, as well as ineffective communication and distractions in the operating rooms. The study showed that by establishing redundant verification procedures in the preoperative rooms the risk of wrong-site surgeries decreased from 52% to 19% therefore increasing patient safety.
Just Follow The Checklist
In the aviation industry, pilots go through a checklist before taking off. Should surgical facilities (ambulatory surgical centers or full blown surgery centers) set their own checklists and follow the same procedure, the number of wrong site surgeries would decrease and patient safety would increase.
For example, marking the incision site with indelible pens should be included in the lists. Mary Reich Cooper, MD, JD, Senior Vice President and Chief Quality Officer at Lifespan Corporation, recently stated that their procedures include having the doctors step out to the holding area to mark the incision with an indelible pen on the patient’s body, which is then verified with the rest of the surgical team once the patient is brought into the operating room.
Similarly, the President of the Commission, Dr. Mark R. Chasin, MD, FACP, MPP, MPH, states that marking incisions with pens that would subsequently wash away during the preparation of the patient before bringing him or her into the operating room results in mistakes that can be resolved by using only indelible pens tested and approved by the hospital.
Commission’s Solutions Tool
The Commission developed a Solutions Tool to help medical facilities identify where and how mistakes occur in the pre operative process and reduce the number of wrong surgeries. Similarly, the commission recommended implementing “time outs” during which all surgeons and staff would stop all they were doing and go through the checklist.
However, a recent study shows that in Colorado alone 107 wrong site surgeries and 25 wrong patient surgeries were performed between 2002 and 2008 despite these recommendations. Communication errors (100 percent of the cases); errors in diagnosis (56 percent) and errors in judgement ((85 percent) were listed as the main causes for these mistaken procedures. The resulting human tragedy: 43 patients significantly harmed, with one of them dying due to a surgery performed on the wrong body part.
If you or a loved one have been the victims of a wrong site surgery, you should immediately contact a law firm experienced in handling these cases. The Miami Dade County