Wrong-stie surgery - A new survey sheds light on this dark subject.

More and more doctors are being allowed to avoid paying for their mistakes. At this point in the history of our country fear seems to drive every decision. We are consumed with fear. Lobbying groups have senses this weakness in our culture and seize the opportunity to drive decisions that go against common sense. This one is no different.  Tort reform measures that allow them to avoid paying for malpractice mistakes will attract the wrong kind of doctor to these states. In this report the AAOS outlines broadly the types of medical mistakes you can expect to see more of in the future.

The most common error, making up 29% of the incidents, was equipment errors. 

“Instrumentation was reported to cause an error about twice as often as an implant (63% of incidents compared to 32%). Implant errors usually involved a missing implant (43% of these cases) or having the wrong implant (29%). Implants breaking either pre- or intraoperatively were fairly rare occurrences. “

Being able to affectively communicate remains an ongoing concern. Communication errors accounted for 25% of the reported errors. These errors took the form of written, verbal or dictated information or, in 23% of these cases; it simply amounted to a failure to communicate anything.

One interesting reported problems is described as follows: “19% of these incidents resulted in a near miss involving the patient, and the error resulted in a negative outcome (including delayed surgery or a revision) in 33% of these cases. 47% resulted in no harm to the patient.” Don’t ask because I have no clue what this means. You’d think if patient safety were involved there would be clarity in describing the problem, but this description says it all.

Wrong-site surgeries continue to be problematic. There were 27 reports of wrong-site surgery, which can include the wrong side, meaning left versus right; or just being in the wrong part of the body when they state to cut. These accounted for 59% of these were wrong-side. The other wrong-site problems were being on the correct side but ultimately in the wrong location. Things like operating on the correct hand but the wrong finger.  These mistakes included doing the wrong procedure and operating on the wrong patient.

What the survey described as the most serious of errors were medication errors. There were eight of those; a mistake that results in several deaths and serious permanent injury to the patient.

What is most interesting to note about this study is the “resistance” to change that protects the patient. “The study's authors report that there has been "resistance" to adopting patient safety protocols and that the introduction of these programs can represent a culture shift in some ORs. While this survey shows that about half of all reported errors don't result in any harm to the patient, it also highlights room for improvement in patient safety and helps to illustrate how outcomes can benefit from relatively simple measures.”

As painful as this may be it’s a necessary component of change that will result in a better health care system.