Surgery on the wrong patient? It's still a problem

By Frederik Joelving

NEW YORK | Mon Oct 18, 2010 5:15pm EDT

NEW YORK (Reuters Health) - A new study from Colorado shows surgery on the wrong body part, or even the wrong patient, is still a problem.

Insurance records show that among some 27,000 adverse events reported by doctors, there were 107 cases of procedures done on the wrong part of a patient's body and 25 done on the wrong patient.

"It is a major preventable problem," said Dr. Martin A. Makary, a surgeon at Johns Hopkins University in Baltimore, who was not involved in the study.

He estimates about one in 75,000 operations go wrong every year in the US -- sometimes with fatal consequences, as in the case of one patient in the new report who died following surgery on the wrong lung.

"In the world of the health care system it ranks low compared to other harms," said Makary, "but it ranks high in terms of preventable harms."

The researchers, led by Dr. Philip Stahel of the University of Colorado in Denver, found significant harm in 43 cases out of 132. Communication errors were involved in all the patient mix-ups; for wrong-site surgery, errors in clinical judgment and lack of a short briefing session before the procedure were the main culprits.

That's despite the widespread use of a protocol to ensure such briefings -- called time-outs -- and making sure that doctors are dealing with the right patients.

"It is not as simple as adopting a checklist, it requires a change of culture," said Makary, adding that operating staff used to be afraid to speak up when they perceived an error.

"There is a very strong hierarchy in the operating room," he told Reuters Health. "Orders are passed on in telegraphic manner. You don't see anyone's face. It is known to be a very intimidating environment."

"We do encourage patients to ask their team to have a briefing discussion before their surgery," said Makary. And they might even want to mark the body part where they are going to have surgery with a permanent marker, he added.

SOURCE: link.reuters.com/qag98p Archives of Surgery, October 18, 2010.

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