This week a Colorado study shows reasons to be scared of hospital procedures. Three healthy men had their prostate glands removed. Five people had surgery on the wrong part of their spines. A child underwent an unneeded ear operation after the wrong person was called to go to the operating room. Despite efforts to end surgical errors, doctors are reporting operations performed on the wrong body parts and even on the wrong people.
The cases were included in a database of errors Colorado doctors reported to the Colorado Physician Insurance Co., or COPIC, between Jan. 1, 2002, and June 1, 2008, according to the study published in the medical journal Archives of Surgery. Of the 27,370 incidents in the database, the study found that 25 surgeries were performed on the wrong patient and 107 operations on the wrong body part. About one-fourth of those operations inflicted “significant harm” on a patient, according to the study. One person died because of a procedure error, the patient suffered acute respiratory failure after a chest tube was placed on the incorrect side.
COPIC insured nearly 6,000 doctors during the study period. Researchers didn’t list facilities where the mistakes happened, but the authors of the study assert the results aren’t unique to Colorado.
Wrong-site, wrong-patient procedures are called “never events” because such mistakes should never happen. This study is viewed as more accurate than previous studies that looked only at closed insurance claims. Nevertheless, the incidence of wrong-site surgery is probably higher than the study suggests because doctors are reluctant to report such events.
A national standard-setting group for hospitals called the Joint Commission tried to cut the number of “never events” with a universal protocol enacted in 2004. Its rules include marking areas of the body for surgery beforehand and taking a timeout right before surgery so that doctors can affirm what is about to happen.
Since 1995, the commission has reviewed at least 921 wrong-site procedures reported voluntarily. In spite of wide-spread “tort reform” measures strictly limiting patients’ rights, the numbers have risen sharply over the years. The Joint Commission argues that the higher rate might be due to better reporting.
The Colorado study found some errors resulted from laboratory mix-ups before patients got to the operating table. The three healthy men whose prostate glands were removed were the victims of mislabeled lab samples.