Sep 22

Wrong Site, Wrong Patient, Wrong Surgery

Wrong site, wrong patient, wrong surgery errors are all considered “never” events by the National Quality Forum. The term “never event” was introduced in 2001 by Ken Kizer, MD, referencing particularly shocking medical errors which should never occur. Over time, “never events” now include any adverse events which are serious, preventable, and clearly identifiable and measurable.

In fact, there are few errors as terrifying to patients as having the wrong body part operated on, having an unneeded, incorrect surgery performed, or undergoing a serious surgical procedure which is meant for someone else. We’ve all heard about a wrong side surgery—the left kidney is taken out when the right is diseased, or the right arm is amputated when it should have been the left. Surprisingly common for neurosurgeons are operations at the wrong level of the spinal column. Wrong patient surgeries also occur.

One such case of wrong patient errors involved a patient who had a cardiac procedure done when the procedure was meant to be for another patient who had a similar last name. The Patient Safety Network observed orthopedic surgeons for a period of six months and found wrong patient surgeries occurred about 5 percent of the time, wrong procedure surgeries about 14 percent of the time and wrong site surgeries a staggering 23 percent of the time.

Wrong Site Surgery the Fourth Most Common Sentinel Event

According to an NCBI article, wrong site surgery is the fourth most common “sentinel event” following patient suicide, operative and post-operative complications, and medication errors. The most common reason for wrong-site surgery is misinterpretation of the radiology report. Wrong patient procedures tend to be much less common, although there have been reported cases of termination of life support of the wrong patient, radiation treatment to the wrong patients and even tonsillectomies to the wrong patient. Patients who undergo the wrong site surgical procedure or the wrong surgical procedure will face increased hospitalization, additional surgical procedures, life-long health issues and even death.

Many Errors Occur Outside the Actual Hospital Operating Room

While these numbers seem extremely high, another study placed the figures much lower, determining that surgical errors occur only in about one out of every 112,000 procedures. It is important to note that this number did not include ambulatory surgeries, interventional radiology surgeries, etc, rather only included hospital operating room surgical procedures. Because of this, it is likely the numbers are much higher than this particular study concluded.

While there were early efforts to prevent these wrong site, wrong patient, wrong surgery errors, these efforts were not particularly successful. When surgical sites were clearly marked, there was still confusion regarding whether the marked site was the area to avoid, or the area to operate on. Despite this, site markings remain a core component in the avoidance of wrong site surgical procedures.

Communication the Primary Issue in “Never” Events

Communication issues appear to be the primary issue related to these “never” events. These communication issues have prompted what is known as a “surgical timeout.” This is a deliberate, planned pause prior to beginning a surgical procedure, giving time to review important aspects of the procedure. The location of the surgery is checked and double-checked, as are the patient and the surgical procedure in question.

While these protocols were originally designed strictly for operating rooms, timeouts are now required prior to any invasive procedure. Surgical safety checklists are commonly used to improve surgical and post-op safety. While these safety checklists and timeouts have reduced the number of wrong site, wrong patient, wrong surgery issues, many errors can happen prior to when the patient reaches the operating room. Further, a timeout could potentially be rushed, contributing to errors during the surgery.

Contact Our Oregon Medical Malpractice Attorneys

The often-permanent harm resulting from a wrong site, wrong patient, or wrong surgery event can be financially and emotionally devastating. If you’ve suffered from a surgical error or medical error, we can help. An experienced Oregon medical malpractice attorney can help you through this difficult time, answering your questions, protecting your rights, and helping achieve a better outcome. Keith Dozier and his associates have successfully recovered millions for injured patients in Portland, Vancouver, Lake Oswego, Salem, and throughout the state of Oregon. Call us today at (503) 594-0333 for a free initial consultation and review of your case.

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