Wrong-Site Surgeries: Can This Happen To You In Kingston, New York?Surgery
Seven years ago, the Joint Commission, the group that accredits hospitals, issued mandatory rules to prevent operations on the wrong patient or body part. The rules require preoperative confirmation of important details, such as marking the surgical site and a “timeout” to verify the details of the operation before it begins. This week the Joint Commission revealed that the mandatory rules have failed to reduce wrong-site surgeries and such medical errors are increasing.
Don’t think a wrong-site surgery can happen to you? Guess again
The problem of wrong-site surgery has not improved and may be getting worse, according to patient safety experts. The Joint Commission estimates that wrong-site surgery occurs 40 times a week in the U.S. hospitals. Wrong-site surgeries have multiple causes: mixing up the left and right sides, marking the incorrect vertebrae in spinal surgery, and neglecting to mark the site. A prime example is three men in Colorado who underwent prostate cancer surgery although tests revealed that they were cancer-free.
Last year a jury returned a $20 million verdict against Arkansas Children’s Hospital for surgery on the wrong side of the brain in a 15-year old boy who was left psychotic and severely brain damaged. The trial testimony revealed that the error was not revealed to the boy’s parents for more than a year after the operation.
The problem, according to the President of the Joint Commission, is that doctors resist checklists, underestimate their propensity for errors and resist standardized procedures. Studies of wrong-site errors have revealed a failure of physicians to participate in a “timeout” as required by the universal rules. Doctors resent the rules even though studies show that orthopedists have a 25 percent chance of making a wrong-site error during their career, according to the American Academy of Orthopaedic Surgeons.
The legal system has not fixed the problem. One study found that only a third of wrong-site cases result in a malpractice suit. The average payment was less than $81,000 in cases resulting in a lawsuit and $47,000 in those resolved without litigation.
What can be done to prevent wrong-site surgeries?
Unfortunately, the rate of wrong-site surgeries are hard to track because half of the states do not require reporting of medical errors. In those states that require reporting of medical errors, the reporting is “spotty” at best with many medical errors unreported. The number of reported cases is “clearly the tip of the iceberg”, according to patient safety experts.
Wrong-site surgeries are the “health-care equivalent of plane crashes”, according to Kenneth W. Kizer, who nearly a decade ago coined the term “never events” as the head of the National Quality Forum. While the airlines have numerous mandatory checklists before a plane can move, physicians routinely flout the rules. So, what can be done about this?
Reducing the number of wrong-site surgeries requires tougher reporting rules and mandatory reporting of wrong-site surgeries to a federal agency so that the cases can be investigated and the results publicly reported. There should be tough financial penalties for hospitals and physicians who fail to report wrong-site surgeries, such as fines and possible revocation of their eligibility for Medicare and Medicaid payments.
Until the federal government imposes mandatory reporting of wrong-site surgeries to a federal agency, the “plane crashes” of wrong-site surgery will remain a serious problem. If you don’t think a wrong-site surgery can happen to you or your loved one, you might want to think again.
If you want more information, here’s what you can do
If you have questions or want more information about wrong-site surgeries, I welcome your phone call on my toll-free cell at 866-889-6882 or you can send me an e-mail at firstname.lastname@example.org. If you send me your name and e-mail address, I will include you on my e-mail newsletter list.