Whose Side Are They On?

The thought of a surgeon taking a scalpel to the wrong limb or patient sends chills down the spine of anyone who has been admitted to the hospital. Eighty-four cases of what’s known in the business as “wrong site surgery” were reported in the United States last year. But that’s just the “tip of the iceberg” because many hospitals across the country aren’t obligated to account for such blunders publicly.

The chances of wrong site surgery are slim–about one in 113,000 operations. Still, any incident is unacceptable. In one typical case, instead of removing a benign tumor from a patient’s right ear last September, surgeons at the Maricopa Medical Center in Phoenix operated on his left ear, which had no tumor.

In an effort to eliminate such blunders, surgeons have been required since 2004 to mark the spot they plan to cut while consulting with their patient before the operation. Nurses are supposed to call a “time out” in the operation room to conduct a final safety check to ensure that the right procedure is performed on the right patient. So, why do these catastrophic mistakes keep happening? Mainly because systems designed to prevent errors are faulty or not followed, researchers say. Some surgeons who think they’d never make such a stupid mistake often ignore safety protocols. Stubborn resistance to standardized conduct is part of the culture of medicine which must be eliminated.

Surgical screw-ups are a small part of a much larger patient safety problem in hospitals. Incidents such as bed sores, postoperative infections and failure to diagnose and treat conditions that develop in the hospital continue to plague American hospitals, according to a new study of Medicare patients by Healthgrades, a health care ratings program.

This study found that 1.24 million patient safety incidents occurred in nearly 40 million hospitalizations from 2002 to 2004. Those incidents were associated with 250,000 potentially preventable deaths and $9.3 billion in excess costs. For the second straight year, the incidents increased slightly.