In 2006, the Department of Health and Human Services’ Agency for Healthcare Research and Quality commissioned a study to determine the prevalence of wrong-site surgeries.

The report examined wrong-site surgeries reported to a medical malpractice insurance carrier between 1985 and 2004, finding that surgeries are performed on the wrong person, wrong body part or using the wrong procedure once in every 112,994 operations. With the proper protocols, the study also found that wrong-site surgeries are completely preventable.

Universal Protocol

The Joint Commission – an independent agency that accredits and certifies health care organizations throughout the U.S. – introduced a universal protocol in 2004 in an effort to reduce wrong-site procedures. The protocol uses a list of processes and procedures to help doctors determine they are performing the correct surgeries on the right patients.

A more recent study, published in the Archives of Surgery, notes that despite use of the universal protocol, wrong-site surgeries are still occurring. Researchers examined over 27,000 self-reported adverse occurrences from physicians, using a database from an insurance company that provides liability insurance to physicians in Colorado.

The study found 107 wrong-site and 25 wrong-patient procedures were performed from 2002 to 2008. Of the adverse events, a total of 43 patients (five of the wrong-patient and 38 of the wrong-site surgeries) were significantly harmed. One person died as a result of surgery being performed on the wrong body part.

The root causes of the incorrect procedures were also examined in the report. Communication errors were the most common, occurring in 100 percent of the cases, errors in diagnosis at 56 percent and errors in judgment at 85 percent.

The lack of a “time out” as recommended by the universal protocol was also a factor in 72 percent of the cases. The Joint Commission defines the time out as an “active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a ‘fail-safe’ mode.” This step is an effort to have all team members stop one last time before the procedure begins to let any concerns be heard.

Getting Help

While the protocols and efforts by hospitals and doctors to stop medical mistakes may reduce the frequency, errors still happen far too often. For people who have been injured in a wrong-site surgery or other act of medical malpractice, it is important to work with an experienced attorney.

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