An agency that regulates hospitals says that surgeons are still making significant mistakes and that many of them aren’t following simple guidelines the group issued two years ago.
Prompted by the continuing errors, the watchdog agency, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), issued another alert this week to 18,000 health-care facilities across the nation.
The errors mentioned in the alert — operating on the wrong patient, performing the wrong procedure, and operating on the wrong site — are all “totally preventable,” says Doctor, executive director for strategic initiatives at the commission.
The phenomenon is hardly an epidemic, and experts caution against hysteria. Only 150 such errors have been reported since 1996.
“These are rare events. The problem is getting them to be zero,” says Doctor, director of the VA Center for Outcomes Research and a professor of medicine and public health at the University of Michigan, both in Ann Arbor. “People shouldn’t be afraid that this is a common thing.”
About 40 percent of the cases, however, involved major procedures, including brain surgery and mastectomy.
The commission presented statistics based on 126 of the 150 cases. Of those, 41 percent occurred during orthopedic/podiatric surgery, 20 percent during general surgery, 14 percent during neurosurgery, 11 percent during urologic surgery, and the remainder scattered among a variety of procedures.
Why are these mistakes happening?
It’s often because the patient got switched to a different operating room or because X-rays were viewed in reverse, the commission says.
The guidelines issued two years ago were intended to reduce this sort of error, it adds.
The main recommendation put out to surgeons was a deceptively simple one: Mark the site of the incision with a permanent marker. Other recommendations included going through a detailed checklist before each surgery and taking a “time out” in the operating room before starting a procedure so that surgical team members can double-check that they’re doing the right thing on the right part on the right patient.
“Of all the cases that we have, none of them occurred in an organization which was following our recommendations,” Croteau notes.