Poor judgment, lack of time-out behind most wrong-site errors

Despite the legal liability hospitals face when the Universal Protocol isn't followed, wrong-site and wrong-patient procedures continue to harm patients, according to findings from a study published in the October issue of Archives of Surgery. "Shockingly, non-surgical disciplines equally contribute to patient injuries related to wrong-site procedures," the authors write.

The findings are based on an analysis of a database from a liability insurance company that contained 27,370 physician self-reported adverse events between Jan. 1, 2002 and June 1, 2008. The database covers 6,000 practicing doctors who are offered incentives for early reporting of adverse events, according to Medical News Today. Among the findings:

  • There were 25 wrong-patient procedures and 107 wrong-site procedures.
  • 20 percent of the wrong-patient procedures significantly harmed the patient.
  • 36 percent of the wrong-site procedures harmed the patient, including one procedure where the patient died.

After examining the root causes behind the wrong-patient procedures, researchers found that they tended to be due to errors in communication (100 percent) and diagnosis (56 percent). Wrong-site occurrences most often were related to errors in judgment (85 percent) and the lack of a time-out (72 percent).

According to Medical News Today, 24 percent of wrong-patient procedures involved internal medicine specialists. Eight percent of wrong-patient procedures involved family practice or general practice doctors, or doctors in pathology, urology, OB-GYN and pediatrics. Orthopedic surgeons were involved in 22 percent of wrong-site procedures.

In 2004, the Joint Commission's Universal Protocol rule for preventing surgery on the wrong site, using the wrong procedure or on the wrong person first went into effect for all accredited hospitals, ambulatory care and office-based surgery facilities. These recent findings, however, suggest that hospitals have still yet to figure out how to get everyone to follow the Universal Protocol to prevent wrong-site or wrong-patient surgeries.

The researchers conclude that "these data reveal a persisting high frequency of surgical 'never events.' Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents."

To learn more:
- read the Archives of Surgery abstract
- read the Medical News Today article

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