Surgical errors happen as much as 40 times a week around country despite guidelines

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Updated: October 20, 2011 12:27AM

It’s the kind of horrifying surgical error that should never happen.

Yet, as often as 40 times a week in the United States, patients come out of surgery to learn that their doctor operated on the wrong body part, did the wrong procedure or mixed them up with another patient.

These errors, known as wrong-site surgeries, remain a problem almost a decade after the Joint Commission Center for Transforming Healthcare, an Oakbrook Terrace-based organization that accredits more than 19,000 health care facilities, issued a universal protocol for preventing them. It includes taking simple precautions such as marking the surgical site and taking a timeout before the first incision to make sure the right patient is getting the right procedure.

But preliminary results from a Joint Commission project involving eight hospitals and surgery centers, including one in Peoria, identified 29 specific areas where errors can creep into the process, increasing the risk for wrong-site surgeries.

They ranged from inaccurate or incomplete documentation on the patient during the scheduling process to distractions in the operating room and lack of full participation in the timeout, the Joint Commission reported last week.

Even seemingly minor mistakes such as using an unapproved pen to mark the site, resulting in the ink being washed away before surgery, can open the door for a wrong-site error, Joint Commission President Dr. Mark R. Chassin said.

“This turns out to be a much more complicated process than we thought it was,” he said. “Risks are introduced at every point.”

Further complicating the matter is the fact that wrong-site surgeries, while potentially devastating, are relatively uncommon.

“They’re so uncommon that an individual surgeon or individual hospital ... may not have experienced one of these in the recent past,” Chassin said. As a result, they may not recognize the importance of following standardized safety procedures correctly and consistently with every patient, he said. Dr. David Ansell, chief medical officer of Rush University Medical Center, agreed, saying hospitals that allow their staff to simply “go through the motions” during safety checks do so at their own peril.

“The reason these failures still occur is one, we’re all human, but more than that, it’s system design that causes the breakdown,” he said.

The eight participants in the commission’s Wrong Site Surgery Project found that when they made changes to their documentation and verification procedures in the pre-operative stage, cases in which additional risks for wrong-site surgery were introduced dropped from 52 percent to 19 percent. Risks introduced in the operating room also fell from 59 percent to 29 percent.

Not every facility had the same problems. So it’s important for hospitals and surgical centers to evaluate their own specific risk factors and adopt strategies to minimize them, Chassin said.

The frequency of wrong-site surgeries in Illinois hospitals is unknown, because the state health department doesn’t report them. Local malpractice lawsuits include allegations of surgeons at two hospitals operating on the wrong side of a patient’s brain and a 2008 case of reconstructive surgery on the wrong knee.

Chicago-area hospitals contacted by the Sun-Times say they follow Joint Commission standards for preventing wrong-site surgery. Some, such as Loyola University Medical Center in Maywood, take additional precautions.

Last year, Loyola launched its “green light process,” which involves the use of green and red plastic flags to indicate that a patient has been cleared for surgery after their identity, lab tests and site marking have been checked. The hospital also limits the number of “handoffs” of the patient between staffers to reduce communication errors, said Debbie Marra, manager of Loyola’s inpatient operating room.

Rush University Medical Center, meanwhile, uses safety checks modeled after those used by the airline industry and Nascar pit crews to prevent wrong-site errors, Ansell said.