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Wrong-Site Surgeries Happen as Many as 40 Times a Day Despite Efforts to Reduce Surgical Errors

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The Washington Post published a short list of "high-profile examples of wrong-site surgery" on June 20, 2011. Casting back to 2006, the newspaper found at least one egregious surgical error for each year, including removal of the healthy testicle from a cancer patient and three operations in a 2-month period at a single hospital in which the doctors targeted undamaged sections of the patients' spines.

surgical error, surgeons, nurses, doctors, medical malpractice, medical mistakesThat catalog of medical mistakes the federal Centers for Medicare & Medicaid Services has dubbed "never events," because they should never happen, came out nine days before a private national health care quality association reported that as many as 40 wrong-site surgeries are performed each day in the United States.

The Joint Commission Center for Transforming Healthcare defines wrong-site surgery as any operation performed on the wrong patient, any procedure other than one scheduled for a patient and any operation done on the wrong side of a patient's body. The last type of wrong-site surgery would include procedures done on the wrong eye, lung, kidney, leg or finger, as well as on any undamaged or healthy section of the body part that does require surgery.

The Joint Commission has been raising awareness about and trying to reduce wrong-site surgeries since 1998. The group claims as one of its chief accomplishments the development and distribution of a "Universal Protocol" for all surgeons, doctors, nurses and surgical technicians to follow when prepping, operating on and providing post-op care for patients.

The Universal Protocol is nothing more than an extensive checklist for members of the surgical team and hospital or outpatient clinic staff. My North Carolina medical malpractice attorney colleagues and I have written several times about the benefits of using checklists in operating rooms. What is disturbing to realize, though, is that debilitating and potentially life-threatening errors like wrong-site surgeries persist despite the widespread adoption of valuable tools and standards like checklists.

The Joint Commission worked with surgeons and other surgical team members at eight hospitals across America to identify why this was the case. The findings, in short, were that health care professionals simply were not using the checklists to confirm patients' identification and mark surgery sites well. Nor were surgeons, doctors, nurses and technicians communicating clearly.

The old saw about tools only being as good as the people who use them apparently proves as true in an operating room as in a woodworking shop. I'm a personal injury lawyer who has represented surgery error victims. Not being a doctor, I cannot offer solutions for the difficulties some health care providers appear to have with following clearly defined safety practices. I do know, however, that correct and complete use of surgery checklists and other patient protection tools is necessary.

EJL
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