MA surgical errors persist despite efforts to address them

Hospital leaders in Massachusetts have been working to reduce surgical error rates for more than a decade. Nonetheless, like peers in other states, health executives have been unable to eliminate major surgical errors.  Between January 2005 and September 2007, the Department of Public Health documented 36 cases involving wrong procedures, wrong surgical sites and wrong patients. In another 38 cases, patients ended up with sponges, surgical instruments or other equipment inside them, requiring further surgery to address the error.

While this is a tiny percentage of the surgeries performed in the state each year, these stats point to a troubling problem, officials say. Despite practices designed to avert "never events" [1] like these, including marking incision sites, verifying patient names and timeouts before surgery to verify procedures and sites, compliance with such procedures is often spotty. In particular, surgeons often don't follow these guidelines, and with nurses and technicians afraid to confront to confront them, such lapses go unchecked.

In response to such trends, both in Massachusetts and elsewhere, the Joint Commission is recommending that professional societies encourage members to follow surgical error prevention protocols, and more, than hospitals show "zero tolerance" for staff and physicians who don't follow error prevention rules.

To learn more about this trend:
- read this item [2] from The Boston Globe

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