OREGON HOSPITALS’ MEDICAL ERRORS: NEVER SAY ‘NEVER EVENT?’

May 1, 2011

In the wake of a well-publicized “never event” at a Portland hospital, patient safety advocates have started to wonder if surgical teams are just going through the motions when it comes to safety protocols. The never event in question involved a wrong side procedure on a 4-year-old that happened even though all the protocols were observed.

The surgery was to correct the little boy’s wandering right eye. The surgical team performed each safety check along the way, including putting a mark over the right eye in the presence of the patient’s parents and taking a mandatory “time out” in the operating room. In the time out, the team confirms the patient’s name, the procedure and the site.

According to the surgeon, though, when she started the operation she was standing at her patient’s head and became disoriented. To make matters worse, the mark so carefully placed above his eye was covered. By the time she realized the mistake, the surgery was already complete.

Wrong site surgeries — along with wrong patient procedures — are at the top of the list of never events for hospitals. For the past decade, hospitals around the country have been following safety procedures designed to forestall any of these events.

And yet, according to a national study, anywhere from 1,300 to 2,700 people undergo wrong site surgeries.

Oregon began to track and report surgical errors in 2006. That year, hospitals reported — voluntarily — eight wrong site and wrong patient surgeries. The state has fared worse in the past two years, with 10 wrong site, wrong patient or wrong procedure errors. One of those never events resulted in the patient’s death.

Part of the challenge in both measurement and prevention of errors is that reporting is voluntary. Hospitals are required to follow protocols by the Joint Commission, a major credentialing authority, but they are not required to report adverse incidents either when a protocol is not followed or when a protocol fails.

Continued in our next post.

Source: OregonLive.com, “Wrong body part, wrong patient surgeries continue despite new procedures,” Joe Rojas-Burke, 05/25/2011

 

Categories: Blog