"It was the worst feeling of my life." Hand surgeon David C. Ring had just performed a carpal tunnel release on a patient and was dictating notes when he realized that he had just completed the wrong operation.
Though Ring was able to correct his mistake, he is not alone in performing wrong-site surgery. According the Joint Commission, a hospital accreditation group, approximately 40 wrong-site surgical errors are performed each week in U.S. hospitals and clinics. Unfortunately, that number seems to be growing.
To prevent wrong-site surgeries or wrong procedures, the American Academy of Orthopaedic Surgeons (AAOS) developed an initiative in 1998 known as Sign Your Site. This initiative encouraged surgeons to mark surgical sites with their initials, thereby lowering the chance of mistake.
In 2003, the Joint Commission decided to build on the AAOS efforts by developing and mandating standardized procedures. Known officially as the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery, the Universal Protocol became effective July 1, 2004 and included three principal components prior to performing surgery: verifying details, marking the surgical site and taking a time out.
At the time, many believed the new requirements would finally result in measurable decreases in wrong operations. Yet, continued evaluation reveals the "never events" that shouldn't happen in fact still do, and much too frequently. In addition to studying the frequency of medical mistakes, researchers have uncovered interesting clues as to why these mistakes continue to occur.
Investigations into wrong-site or wrong-procedure surgeries indicate the Universal Protocol is being ignored. Though doctors provide lip service to the requirements, they fail to fully participate because of:
- Distractions
- Time pressures
- Resistance to checklists
- Resentment due to lack of autonomy
- Underestimation of their propensity for error
Tragically, the doctors are not the only ones to blame for the mistakes. Often other doctors, nurses or medical personnel may notice a problem, but they fail to speak up or to challenge the surgeon in charge.
Some believe the only way to reduce wrong surgeries, increase patient safety and eliminate hospital errors is to change hospital culture. According to John Clarke, clinical director of the Pennsylvania Patient Safety Authority, there is a noticeable difference between hospitals that are patient focused and those that are doctor focused. "The staff needs to believe the hospital will back them against even the biggest surgeon."
Kenneth W. Kizer, former California chief health officer, believes more accountability is key. Because some states do not require reporting of medical errors, Kizer advocates the development of a federal reporting agency. Other experts call for simply clarifying the Universal Protocol and barring surgeons from moving into the operating room until they have completed presurgical checks.
Though proposed solutions to the wrong-site surgery dilemma are plentiful, the problem continues to exist. "It's very frustrating," said Clarke. "If you can't solve the wrong-site-surgery problem, what can you solve?"
If you or a loved one have been a patient who's undergone a wrong-site surgery and subsequent recovery, an experienced Rhode Island medical malpractice attorney can help you fight back. Doctor, physician, surgeon and/or hospital negligence should not force you to live with the consequences of another's mistake without having options.
WRNI & WGBH Radio Stations