Surgical Errors: Wrong-Site, Wrong-Procedure & Wrong-Patient

Surgical Errors: Wrong-Site, Wrong-Procedure & Wrong-Patient2018-01-22T16:19:06+00:00

Doctors call major surgical errors “never events” – mistakes that should never happen. Wrong-site, wrong-procedure and wrong-patient surgical mistakes often have catastrophic results, leading to severe injuries or permanent disability. In most cases, these errors are entirely preventable.

Surgical Malpractice: Errors In & Out Of The Operating Room

Serious surgical mistakes are universally avoidable, according to researchers at the University of Chicago. “Never events” are nearly always examples of medical malpractice – extreme and negligent breakdowns in the standard of care.

Surgeons During Operation

When surgeons operate on the wrong body part, perform an incorrect procedure or mistake one patient for another, these mistakes are not minor lapses in individual judgment. Almost every major surgical error is the result of numerous mistakes, a Domino effect of miscalculation, incompetence and bad communication.

In short, surgical errors don’t begin and end with a surgeon. Most significant mistakes are caused by poor planning during pre-operative sessions and inadequate communication between healthcare professionals.

How Common Are Surgical Errors?

While major errors are relatively rare, and surgical error statistics vary, most studies suggest that around 2,500 to 4,000 significant surgical mistakes occur every year.

Every week, surgeons:

  • leave foreign objects inside a patient 39 times
  • perform the wrong procedure 20 times
  • operate on the wrong body part 20 times

Considering the severity of these mistakes, 4,000 is not a small number.

High Mistake Risks In Dental, Orthopedic Surgery

Studies have found that wrong-site, wrong-procedure and wrong-patient surgical errors are most likely to occur in dental and orthopedic practices. Mistakes during spinal surgery, despite the serious consequences of such errors, are also surprisingly common.

Surgical mistakes are often explained away as the errors of young and old surgeons, physicians too immature or too fatigued to conform to best practices. In his own research, Johns Hopkins surgeon Marty Makary has found otherwise. Patients between 40 and 49 are most likely to become the victims of a “never event” – and surgeons within the same age range are most likely to commit a major surgical error.

“Surgeons involved in retained sponges,” Makary told WebMD, “tend

[…] to be in the middle part of their career, dispelling the idea that surgeons at the beginning or end of their careers have most of these events.”

Surgical Errors “Unreported”

Doctors, however, tend to underestimate the true incidence of wrong-site, wrong-procedure and wrong-patient procedures. Reports of wrong-site, wrong-procedure and wrong-patient errors almost never make their way into medical journals. When doctors learn about catastrophic surgical mistakes, they do so just like the rest of us – from reports in the mainstream media, not the publications intended for serious therapeutic discourse.

Miscalculating the rate of disastrous surgical mistakes is not a minor problem, since it can make good physicians less vigilant before and during their own procedures. The more serious problem, however, is that doctors are extremely unwilling to report “never events.”

“Many never events go unreported,” Makary says. While hospitals are required by law to report serious surgical errors, some mistakes don’t become apparent until long after a patient has left the hospital.

Wrong-Site Surgery

Studies suggest that, while horrifying, wrong-site surgical errors are relatively rare. In a study funded by the Agency for Healthcare Research & Quality, researchers found that wrong-site surgeries occured in only 1 of every 112,994 procedures between 1985 and 2004. For comparison, surgeons are nearly ten times as likely to leave a foreign object inside their patient.

While heartening to some, this number is only an estimate. The study analyzed surgeries performed in formal operating rooms, not procedures conducted in ambulatory surgery centers or out-patient facilities. But in today’s healthcare system, more surgeries occur in out-patient settings than hospitals. Thus, including procedures performed outside the operating room likely increases the rate of wrong-site surgeries significantly.

Surgical Instruments In Operating Room

Interviewing 400 neurosurgeons, researchers at the University of Texas found that a striking 50% said they had performed at least one wrong-level surgery during their careers. While only one of these errors resulted in permanent disability, more than 70 of the mistakes led to legal action and monetary settlement. Other estimates have been even higher. A 2014 survey, which anonymously questioned 173 members of the North American Spine Society, found that up to 68% of respondents had operated at the incorrect spinal level at least once.

Wrong-Patient Surgical Errors

As healthcare becomes more complex, patients are being misidentified at increasing rates, according to a new report from the Wall Street Journal. Compared to doctors in earlier generations, today’s healthcare practitioners perform more lab testing, more diagnostics and more procedures than ever before. Each of these patient-encounters is logged, and likely sent off to multiple health insurance companies and state organizations.

Despite new technologies to help physicians sift through the records, each new log presents the risk of a patient-identification mix-up. Old-fashioned misidentification is still surprisingly prevalent, too. Patient wristbands can be wrong or illegible, leading doctors to apply treatments intended for other patients.

In a classic case of wrong-patient surgery, frequently-cited in the medical literature, surgeons at New York’s Mount Sinai School of Medicine performed an invasive electrophysiology procedure on 67-year-old Joan Morris. Around one hour into the surgery, it became clear that Morris was the wrong patient. Jane Morrison, not Joan Morris, had been scheduled for the procedure, but “at least 17 distinct errors” had placed Morris, not Morrison, under the knife.

What Is Surgical Malpractice?

Surgical errors aren’t always medical malpractice, although the majority of serious surgical mistakes – what researchers call “never events” – involve at least some level of negligence.

A surgical mistake becomes malpractice when a surgeon, anesthesiologist, nurse or other healthcare practitioner deviates from the accepted standard of care and harms a patient.

Harm is a necessary component of any medical malpractice case. In a lawsuit, patients will have to prove that they suffered injuries and that those injuries were caused by a healthcare professional’s negligent mistake. Our New York surgical error malpractice lawyers help guide patients through this process.

New York Won’t Tolerate “Avoidable” Surgical Errors

New York’s Medicaid program does not reimburse hospitals for costs associated with a “never event.” In 2008, the state’s Health Commissioner announced that 14 serious medical errors had been deemed “unreimbursable.” Surgical mistakes topped the list:

  1. surgery performed on the wrong body part
  2. surgery performed on the wrong patient
  3. wrong surgical procedure on a patient
  4. foreign object inadvertently left in patient after surgery

As of 2008, hospitals that receive Medicaid payments through New York’s state system are required to report the health complications that patients have upon admission, along with those that develop during or because of hospital care.

Based on those reports, the state decides whether or not to reimburse the facility for healthcare costs, depending on medical errors committed during treatment. The surgical errors have been classified as ineligible for reimbursement because they are “avoidable hospital complications, medical errors that are identifiable, preventable and serious in their consequences to patients.”

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