Preventable Surgical Errors Still Happening

Agency says doctors fail to follow simple guidelines

FRIDAY, Dec. 7, 2001 (HealthDayNews) -- An agency that regulates hospitals says that surgeons are still making significant mistakes and that many of them aren't following simple guidelines the group issued two years ago.

Prompted by the continuing errors, the watchdog agency, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), issued another alert this week to 18,000 health-care facilities across the nation.

The errors mentioned in the alert -- operating on the wrong patient, performing the wrong procedure, and operating on the wrong site -- are all "totally preventable," says Dr. Richard Croteau, executive director for strategic initiatives at the commission.

The phenomenon is hardly an epidemic, and experts caution against hysteria. Only 150 such errors have been reported since 1996.

"These are rare events. The problem is getting them to be zero," says Dr. Rodney Hayward, director of the VA Center for Outcomes Research and a professor of medicine and public health at the University of Michigan, both in Ann Arbor. "People shouldn't be afraid that this is a common thing."

About 40 percent of the cases, however, involved major procedures, including brain surgery and mastectomy.

The commission presented statistics based on 126 of the 150 cases. Of those, 41 percent occurred during orthopedic/podiatric surgery, 20 percent during general surgery, 14 percent during neurosurgery, 11 percent during urologic surgery, and the remainder scattered among a variety of procedures.

By far, the majority -- 75 percent -- involved operating on the wrong part of the body; 13 percent involved cutting open the wrong patient, and 11 percent involved the wrong procedure.

Why are these mistakes happening?

It's often because the patient got switched to a different operating room or because X-rays were viewed in reverse, the commission says.

The guidelines issued two years ago were intended to reduce this sort of error, it adds.

The main recommendation put out to surgeons was a deceptively simple one: Mark the site of the incision with a permanent marker. Other recommendations included going through a detailed checklist before each surgery and taking a "time out" in the operating room before starting a procedure so that surgical team members can double-check that they're doing the right thing on the right part on the right patient.

"Of all the cases that we have, none of them occurred in an organization which was following our recommendations," Croteau notes.

Why not do something as seemingly simple as X marks the spot?

"For the most part, it was resistance on the part of the surgeons -- 'This couldn't happen to me,' or 'The patient will lose confidence in me,'" says Croteau, "When we've talked to patients, they think it's a great idea."

Because not all surgeons are listening, the commission is turning its attention to the patients.

"The key message here is that the patient is part of the health-care team, and the patient can help with his or her own safety by asking their surgeons to mark the site," Croteau says.

"I agree completely with the Joint Commission that patients should ask, 'What test am I going for?' And marking a limb might make sense, but we're talking about a very, very low risk," Hayward notes.

The commission is also going to raise the stakes for hospitals and other ambulatory facilities. Right now, the "recommendations" lie somewhere between voluntary and mandatory, but the balance is likely to shift towards mandatory.

"Within the next year, we will begin a process of actively evaluating compliance with these recommendations under our accreditation standards. This makes it much more of a requirement," says Croteau.

If the facilities fail to take appropriate actions to prevent wrong-site surgery, he adds, "they could ultimately lose their accreditation."

What To Do

The Joint Commission on Accreditation of Healthcare Organizations advises consumers to:

  • Discuss your surgery with your surgeon and your primary care doctor and make sure all parties agree on exactly what will be done during the operation;
  • Ask to have the surgical site marked with a permanent marker and to be awake when the site is marked;
  • Speak up if you have any concerns. It's OK to ask questions and expect answers that you understand;
  • Think of yourself as an active participant in your health care. Studies show that patients who are actively involved in making decisions about their care are more likely to have good outcomes;
  • And insist that your surgery be done at a JCAHO-accredited facility. These hospitals and surgery center have undergone rigorous on-site evaluations.

To find out if a facility is accredited, visit the JCAHO's Quality Check.

For more detailed information on preventing medical errors, visit the Agency for Healthcare Research and Quality.

For more information on the work of the JCAHO, click here.

SOURCES: Interviews with Richard Croteau, M.D., executive director, strategic initiatives, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill.; Rodney Hayward, M.D., director, VA Center for Outcomes Research, and professor of medicine and public health, University of Michigan, Ann Arbor; Joint Commission on Accreditation of Healthcare Organizations press release
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