The new study published in the Archives of Surgery, found in spite of the adoption of the Universal Protocol in 2004, wrong-site, wrong-patient surgery events, which have been described as “never events,” (i.e. events that should never happen) are still occurring.
Researchers found that between 2002 and 2008, there were 27,370 self-reported adverse events. Twenty-Five procedures took place on the wrong patient, and 107 were wrong-site procedures.
Significant harm was inflicted in five wrong-patient procedures and 38 wrong-site procedures. One patient died secondary to a wrong-site procedure.
Wrong-Patient SurgerySelf-explanatory, this happens when doctors perform surgery on the wrong patient. Poor communication is the leading cause.
Wrong-Site SurgeryThis is surgery performed on the wrong site on the patient’s body. Sometimes this is due to "lateralization," the fact that there are two, similar features, such as two arms, lungs, kidneys, or eyes, which makes it easier to confuse which one should be operated on.
Many other factors can contribute to a wrong-site, ranging from errors in the diagnosis and judgment of the doctor, to communication and planning of the actual surgery.
Universal ProtocolThe universal protocol was designed to create a process to verify the correct patient is receiving the correct procedure. In addition to the pre-operative verification, there is a “time out” should be conducted in the OR/procedure room before the procedure/incision. This “time out” should include the entire operative team, use active communication, be documented, such as in a checklist, and should include:
- Correct patient identity.
- Correct side and site.
- Agreement on the procedure to be done.
- Correct patient position.
- Availability of implants and/or special equipment.
This is designed force everyone to take the time to double check what they are about to do.
This study demonstrates that there is room for improvement: as an included invited critique notes, this report does not show the mistakes are increasing, but the reporting of them is; nonetheless, these types of errors are stupid for the most part and are clear negligence. This is why they are classified as "never events." They should never occur.
ConclusionsThe report concludes, "Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures. Inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome. On the basis of these findings, a strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to achieve a zero-tolerance philosophy for these preventable incidents."
