IT HAPPENS EVERYWHERE

October 20, 2010 — Wrong-site and wrong-patient procedures are more common than the medical community might care to admit, and clinicians in both surgical and nonsurgical disciplines share equal responsibility for the unacceptable errors, write investigators in the October issue of the Archives of Surgery.

A review of physician-reported adverse outcomes from a Colorado liability insurance database revealed 25 wrong-patient and 107 wrong-site procedures during a 6.5-year period. The wrong-patient procedures included 5 cases of significant harm, including 3 unnecessary prostatectomies resulting from a mix-up in pathology samples. Wrong-site procedures included an errantly placed chest tube that lead to the patient's death from pulmonary decompensation, report Philip F. Stahel, MD, from the departments of Orthopaedic Surgery and Neurosurgery at the Denver Health Medical Center, University of Colorado School of Medicine, and colleagues.

"Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures. Inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome. On the basis of these findings, a strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to achieve a zero-tolerance philosophy for these preventable incidents," the authors write.

The actual incidence of wrong-site surgery is likely to be higher than that determined by the authors, who had to rely on physician self-report of errors to a database that was not anonymous, notes Martin A. Makary, MD, MPH, from the Department of Surgery at Johns Hopkins University in Baltimore, Maryland, in an accompanying editorial.

"This study alerts us, yet again, to the alarming problem of preventable errors — a systems issue that should have been engineered from surgical care long ago. Instead, we are only now beginning to realize the magnitude of the problem," Dr. Makary writes.

Dr. Stahel and colleagues in Colorado and at the Geisinger Medical Center in Danville, Pennsylvania, retrospectively reviewed data on 27,370 adverse outcomes reported by physicians to the Colorado Physicians Insurance Company. Their goal was to determine the frequency, cause, and outcomes of wrong-site, wrong-patient procedures after widespread adoption of the Universal Protocol proposed by the Joint Commission on Accreditation of Healthcare Organizations.

As stated earlier, a total of 107 wrong-site and 25 wrong-patient procedures were identified. Internal medicine specialists accounted for 24% of wrong-patient errors, followed by (at 8% each) family/general practitioners, pathologists, urologists, obstetrician-gynecologists, and pediatricians.

Orthopedic surgeons were responsible for 22.4% of wrong-site procedures, followed by general surgeons (16.8%) and anesthesiologists (12.1%).

Errors in diagnosis were responsible for 14 of the 25 wrong-patient mistakes (56%) and for 13 of the wrong-site failures (12.1%). Errors of communication occurred in all of the wrong-patient cases and in nearly half of the wrong-site cases. In contrast, errors in judgment, primarily inadequate procedure planning, occurred in the large majority (85%) of wrong-site cases, but in only 8% of the wrong-patient errors.

Other causes for mistakes included wrong indications for a procedure, failure to take a "time-out" before a procedure (in 72% of wrong-site cases), and other system-related issues.

As noted earlier, 1 patient died from acute respiratory failure when an internal medicine specialist placed a chest tube in the wrong side. Other wrong-site errors leading to significant harm included wrong-level spine surgery, wrong-site vascular procedures, wrong enterocolic resection, wrong-organ resection, and wrong-sided ovariectomies, eye surgeries, craniotomies, ureteric procedures, and maxilofacial surgery. There were also 2 cases of unintentional irradiation of an organ that was not targeted by radiation and was out of the planned radiation oncology treatment field.

Only 36% of wrong-patient cases and 2.8% of wrong-site cases caused no harm, the authors noted.

They acknowledged that the actual number of erroneous incidents may have been higher, as the database they used covers many, but not all, of Colorado's physicians.

The authors call for universal adoption of the Universal Protocol, which was recently folded into broader National Patient Safety Goals issued by the joint commission. However, Dr. Makary warns that systems alone are not enough to prevent errors.

"Finally, in an era of dissecting hospital systems," he writes, "we must not let up on teaching individual responsibility. The moral hazard of the Universal Protocol is that we can rely on it in place of ourselves. Although I would agree that Universal Protocol compliance is important, it is not the magic wand of Merlin."

Three study authors are employees of the Colorado Physician Insurance Company, including one who serves as the company's chief executive officer. Two other study authors serve as consultants for the company. Dr. Makary has disclosed no relevant financial relationships.

Arch Surg. 2010;145:978-984. Abstract