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Despite Checklists, Wrong-Site Surgery Still Occurs. Why?

Mon, 12/02/2013 - 9:57am
Skeptical Scalpel

Not long ago, two California hospitals were cited by the state for wrong-site surgery.

At one hospital, a skin incision was made in the right groin of a patient who was to have had a left orchiectomy. Fortunately the error was discovered, and the skin was closed. The correct testicle was removed. To his credit, the surgeon told the patient and his wife what happened immediately after the operation.

An investigation found that the patient's groin had not been marked. The time out did not prevent the error because the OR team did not verify the operative site as the protocol mandates. In other words, they had gone through the motions.

The hospital was fined $75,000.

The other California case did not turn out as well. Instead of removing a cancerous left kidney, surgeons did a right nephrectomy. The error was not discovered until the pathology report was reviewed. A number of assumptions and misunderstandings contributed to this error for which the hospital was fined $100,000.

Both hospitals made the usual system and protocol corrections that are precipitated by any state investigation. But these were human errors and will likely happen again. The existing policies were adequate. They simply were not followed.

Another case that occurred in July is from Florida. A surgeon performed a vascular procedure on the wrong leg. Apparently, a nurse anesthetist noticed the error during the case and spoke up, but the surgeon didn't stop. He finished the wrong leg and then did the correct leg too.

When the patient awoke, the surgeon asked her to sign a consent form for the wrong leg and told her that she had needed that surgery anyway.

The hospital failed to report the error for two weeks.

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