Check that your universal protocols are being enforced to prevent the kind of tragic mistake that ended with a physician operating on a the wrong eye of a young boy. Yesterday, the physician told the family she had marked the correct site before surgery, but that her marks had been "covered up" somehow during the procedure, causing her to operate on the wrong eye, reports ABC News.
It's the kind of error that should have been caught in the final checks of the required time-out period. Not taking the time-out causes a whopping 72 percent of the mistakes involving surgery on the wrong side of the body, according to study published in the Archives of Surgery last October.
But even universal procedures may not be enough, study author Philip F. Stahel, and visiting associate professor with the University of Colorado School of Medicine in Denver, told Health Day News. "Once we were fully responsible for our actions--now we hide behind a safety system that should cover the problem. The time-out is performed, but people are not mentally involved--the system alone cannot protect you from wrong-site surgery," he said.
The Portland Ore. case, which happened at Legacy Emmanuel Medical Center, indicates physicians also may need training on how to handle surgical mistakes when they occur. The part of the scenario that wasn't covered under universal protocols was the physician's in-the-moment decision to operate on the correct eye after discovering her mistake, but without consulting the family or any other medical staff, notes ABC News.
To learn more:
- read the ABC News story
- check out the Health Day News article
- get more detail on the Archives of Surgery report
- learn more from the New York Times coverage