Surgeons and Referring Physicians are Responsible for Wrong Site and Patient Procedures

A revealing report of an analysis of a prospective physician insurance database containing 27,370 physician self-reported adverse occurrences in the state of Colorado from January 1, 2002, to June 1, 2008 has appeared in the Archives of Surgery Journal.

The study which was looking only for certain surgical events found that a total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%)and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a “time-out” (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.

The authors conclude that the data reveals a persisting high frequency of surgical “never events.” They call for strict adherence to the “Universal Protocol” by nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.

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