Three Surgical Mistakes Have Occurred At One Boston Hospital Since Sept.

Federal and state health investigators have cited a Boston teaching hospital for making at least three surgical mistakes in the last four months of 2010. 

Health officials said that the Beth Israel Deaconess Medical Center had three incidents since September 2010, where surgeons operated on the wrong vertebrae during spinal surgery. Two of the operations were conducted by the same surgeon, however none of the doctors’ names were released.

The surgical errors were reported to the Massachusetts Department of Public Health. The full report is likely to be made public after the hospital submits a corrective plan of action, which is due January 7.

Hospital officials say that that the incidents were unrelated and attributable to human error on the part of the surgeons. However, the sudden spike in spinal surgical mistakes was notable since hospitals across the state reported only a total of 11 such types of medical malpractice from 2006 through 2008.

Experts consider wrong-site surgical mistakes as “never” events, which should not happen if the surgeon and medical staff follow the appropriate standards of medical care. The hospital said it had procedures in place to prevent such errors, and said it could not explain how the incidents happened if those procedures were being followed.

In a study published in the Archives of Surgery in November, U.S. researchers found that errors in judgment were involved in 85% of wrong-site surgery mistakes and that in 72% of the medical mistakes in the operating the surgical team failed to take a “time out” to assess the situation and make sure their surgical plan was correct.

In all three cases in Boston the doctors completed the surgery without realizing that the vertebrae they were working on was undamaged and just below or above the part of the spine that was actually injured. Two of the errors were discovered during post-surgical X-rays, when patients continued to suffer back pains, and the third was discovered in a routine postoperative X-ray. The patient in the third case felt that their back pain had lessened after the surgery.

One of the patients alleges that the operating room error caused her to suffer limited mobility due to the buildup of scar tissue that reduced her flexibility, according to a report by The Boston Globe. The patient also claims to suffer from other complications and still has back pain.