June 1, 2011

We were talking about medical errors in Oregon hospitals. The problem persists, in spite of safety protocols and error reporting mechanisms. It’s not only an issue in Oregon, of course. Nationally, between 1,300 and 2,700 people suffer wrong site surgical errors every year. But the Oregon Patient Safety Commission report the number of wrong site or wrong patient “never” events has increased in the past couple of years.

Researchers have tried to understand how wrong site surgeries come about. Some studies have found that surgeons easily confuse left and right when standing over a patient. While we don’t recommend anyone try the surgery at home, it is interesting to experience the disorientation that happens when you’re standing over someone instead of looking at him face-to-face.

At times, the surgical site itself is difficult to isolate. In spinal surgery, for example, the healthy sites are almost indistinguishable from the unhealthy target sites.

In Oregon, almost two-thirds of last year’s errors were related to miscommunication. Similar patient names can easily cause confusion.

It is just these errors, though, that the surgical site marking and time outs (described in our last post) were designed to short circuit. Safety protocols may come and go — or even be piled on — but the errors don’t go away.

Medical safety experts suggest there may be a cultural resistance to these protocols. These are highly skilled, highly educated practitioners, and the safety measures may feel a little nursery school to them. There is also the added pressure to schedule more and more procedures every day — if nothing else, the sheer volume of procedures will generate more never events.

Others point out that the numbers may be up but patient outcomes are still good. The data from Oregon reported errors shows a decline in the severity of harm resulting from wrong site surgeries.

In the end, patient safety is about patient safety. If there are errors, even never events, but there is no impact on the patient’s health, what’s the complaint?

Well, first, let’s talk about the effect on the patient and the patient-doctor relationship. Next, let’s talk about the cost, and then ….

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


Categories: Blog