Wrong Site, Wrong Procedure, Wrong Patient Surgery
26 Sep 2015
Are you scheduled for surgery? If so, there are ways to circumvent horrendous surgical errors. We’ve all heard stories about surgeons amputating the wrong leg. Or fixing a hernia on the side that didn’t need it. If you think this is past history, you had better think again as it happens every year in North America.
During a 10 year period in Canada, wrong-site surgery happened 106 times. Each year, 6.3 cases involved a lower extremity and in 4.3 cases, an upper limb. The most common error was the use of arthroscopy (looking into the joint with an optical instrument) on the wrong joint. This misfortune happened to 24 patients. And in one case a total knee replacement was performed on the wrong knee!
One mishap occurred after a patient fell, causing a fracture of the left leg. But operating room nurses placed her on her left side exposing her to surgery on her right leg. It was only after the surgeon made the incision and found no fracture that he realized the error.
Reports from the U.S. show that wrong side or wrong person surgery happens once in every 100,000 cases. But if a patient is having an operation for a lazy eye, the risk of surgery being performed on the wrong eye is one in 10,000!
Dr. Philip Stahel, a researcher and surgeon at Denver Health Medical Center, remarked, “The surgical blunders reported are in all probability just the tip of the iceberg and mix-ups are likely higher.” In fact, one patient died of lung complications when a doctor inserted a chest tube into the wrong lung.
All of these errors are tragic and some catastrophic. In another case, two patients had prostate biopsies. The result showed that one had cancer and the other did not. But the biopsies got mixed up and the patient without the cancer had a radical prostatectomy performed, which is extensive surgery, and removal of an organ, for no reason. The other patient was still walking around unaware he had a malignancy.
The U.S. report showed that one-third of the mistakes lead to long-term negative consequences. In Canada, wrong site, wrong procedure and wrong patient surgery left 10 percent of patients with poor outcomes, depression or death. But all patients either required prolonged surgical time or additional surgery.
One would wonder how these errors can happen. It is primarily a failure of common sense. In some instances the patient was anesthetized, the extremity prepared and draped before the patient was even seen by the surgeon.
In other situations the extremity that supposedly required surgery was marked by someone other than the operating surgeon. Or medical records and X-rays were not available in the operating room. In effect, hospital policy was rarely followed, or not at all.
To help prevent this problem some hospitals have initiated a “timeout” before the incision is made. This gives everyone a moment to reflect on whether all the I’s have been dotted and all the T’s crossed before proceeding.
But what can patients do to prevent wrong-site surgery and make errors as fool proof as possible. Some surgeons initial the part of the body scheduled for surgery. But this is not always done. So if there’s no initial on your operative site before you’re wheeled to the operating room, ask the surgeon to place his initial on the right extremity while you’re still awake.
Alexander Pope wrote over 300 years ago, “To err is human” so it may be a long time before there’s 100 percent protection against surgical errors. It can be so easy to err. For example, a plastic surgeon was about to operate on a patient’s fourth finger. But a colleague entered the operating room to ask a question about another patient. This distraction resulted in the surgeon operating on the third finger!
Last week I wrote about UTI Drops, a natural remedy to treat urinary tract infections. Many readers ask “Where can I purchase them?” You can obtain them at a Health Food Store or go to “pno.ca” and click on store locator to find an HFS near you.
