In 2003, the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery was developed by the Joint Commission Board of Commissioners to reduce the alarmingly frequent occurrence of these types of surgical errors. On July 1, 2004, the protocol became mandatory for all accredited U.S. hospitals, ambulatory-care clinics and inpatient surgical centers-including those in the state of Connecticut. However, more than seven years later the number of these surgical malpractice errors is still much too high, putting too many patients at risk of medical errors.
The Universal Protocol
The Joint Commission is the accrediting body for all hospitals and medical-care facilities in the U.S. It created the Universal Protocol (based on a series of requirements included in its National Patient Safety Goals) in hopes of reducing the occurrence of the wrong type of surgeries, surgeries performed on the wrong patient or on the wrong body part. The key components of the Universal Protocol are:
- Pre-procedure verification of the patient, surgical site and procedure to be performed
- Marking of the site to be operated on
- A mandatory time out before beginning surgery to ensure everything is correct
The Universal Protocol was revised in 2010 to “address patient safety issues” while granting health-care facilities “flexibility in applying the requirements.” However, the Universal Protocol seems to have made little, if any, improvement in reducing wrong-site, wrong-procedure and wrong-person surgeries.
Wrong-Site Surgeries Increasing
According to the Washington Post, Joint Commission officials estimate that wrong-site and similar surgical errors occur 40 times each week in U.S. hospitals and clinics. And although self-reported data may not accurately reflect the true number of wrong-site surgeries, they appear to be on the rise. In 2004, 49 cases were reported to the Joint Commission; in 2010, 93 instances were reported.
In 2010, the Denver Health Medical Center performed a study of 132 wrong-site and wrong-patient surgical errors reported to a large medical-malpractice insurer in the state. The study revealed that, from 2002 to 2008, a third of the reported surgical errors resulted in serious injury to or death of the patient. For instance, in three cases, men underwent prostate cancer surgery when, in fact, they did not have cancer at all. In 72 percent of the reported wrong-site and wrong-person surgery cases, the mandatory pre-surgery time out did not occur.
Wrong-Site Surgery Causes
According to the Washington Post, wrong-site surgical errors are attributed to a handful of causes. Doctors or medical staff may easily:
- Confuse the left and right sides of the patient
- Accidentally reverse x-ray slides
- Operate on a patient who mistakenly received someone else’s test results
- Fail to appropriately mark the correct surgical
- Fail to act when observing potential mistakes
- Fail to challenge the surgeon in charge if there is appearance of impropriety
Many patient-safety advocates say a change in operating-room culture is necessary to achieve a reduction in wrong-site, wrong-person and wrong-procedure surgical errors. Surgeons typically value their independence and may resent being required to complete a checklist or follow redundant safety procedures.
In some hospitals and clinics, a perceived or real air of intimidation and superiority can prevent nurses and surgical assistants from speaking up when they see potential problems. However, the too-often occurrence of wrong-site and similar surgical errors – and their potential for significant harm – brings to mind the old adage that it is better to be safe than sorry.
Ways to Reduce Wrong-Site Surgery
Doctors, patient-safety advocates and medical malpractice lawyers agree that the current number of wrong-site, wrong-person and wrong-procedure surgeries is unacceptably high, and several offer recommendations to eradicate the problem.
According to the Washington Post, researchers say the manner in which a time out is performed and where it occurs makes a significant difference. Surgical errors are far less likely when surgical sites and procedures are verified before the patient enters the operating room. In addition, surgical errors are less likely when the surgeon explicitly asks everyone on the surgical team to speak up if they have concerns.
In addition, experts stress the importance of a simple, yet essential tool: marking pens with approved indelible ink. Frequently, site markings are washed away during surgical prep, negating the value of pre-procedure verification and site marking.
Individuals harmed by wrong-site, wrong-person or wrong-procedure surgery are not without recourse. Patients in Connecticut who experienced this type of medical error may be entitled to compensation. Contacting a Connecticut medical malpractice attorney to discuss possible legal claims is recommended.