Wrong-Patient, Wrong-Site Surgery Mistakes Disturbingly Frequent: Study

Preventable surgical mistakes where the surgeon operates on the wrong person or the wrong part of the body, account for half of one percent of all operating room errors, or one in every 200, according to new research. 

The findings, which were published in the October issue of the Archives of Surgery, surprised U.S. researchers, who did not expect to find such a high rate of avoidable medical malpractice.

Experts consider wrong-site and wrong-patient surgery mistakes as “never” events, which should not happen if the surgeon and medical staff follow the appropriate standards of medical care.

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In the study, researchers examined a Colorado database of 27,370 physician self-reported adverse occurrences between January 1, 2002 and June 1, 2008. They found 25 instances where surgery was performed on the wrong patient and 107 instances where surgery was performed to the wrong part of the body, 20% of which resulted in significant harm to patients and 1% of which resulted in death.

Errors in communication were a factor in 100% of the wrong-patient surgeries, and 56% were a result of misdiagnosis. In wrong-site surgeries, errors in judgment were involved in 85% of the cases and in 72% of the medical mistakes the operating team failed to take a “time out” to assess the situation and make sure their surgical plan was correct.

In different study published last month in the Journal of the American Medical Association, researchers found that Veterans Health Administration medical teams who worked together and created a surgery checklist dramatically reduced mortality and medical mistakes in the operating room. When tactics such as pre-surgery briefings, teamwork and surgery checklists were employed at 74 VA hospitals over three years, surgery mortalities dropped 18 percent.

Researchers examined a program that was started at VA hospitals in 2003 and is in place in nearly all of its 130 surgical centers nationwide. Instead of the head physician dictating the entire surgery, the surgical team members create a checklist and have a team briefing before, during and after the surgery. The program also involves patients identifying themselves and what surgery they have been told is going to be performed before being sedated, and also get to hear the checklist being read off.


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