But seven years later, some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse, although spotty reporting makes conclusions difficult. Based on state data, Joint Commission officials estimate that wrong-site surgery occurs 40 times a week in U.S. hospitals and clinics. Last year 93 cases were reported to the accrediting organization, compared with 49 in 2004. Reporting to the commission is voluntary and confidential — to encourage doctors and hospitals to come forward and to make improvements, officials say. About half the states, including Virginia, do not require reporting. In two states that track and intensively study these errors, 48 cases were reported in Minnesota last year, up from 44 in 2009; Pennsylvania has averaged about 64 cases for the past few years.
Attention to the problem comes at a time of increased focus on the broader issue of medical errors, which a recent Health Affairs study found affected one-third of hospital patients. The federal government recently rolled out its Partnership for Patients program aimed at reducing medical mistakes. Medicare requires reporting and does not pay for wrong-site surgery, and many insurers have followed suit. Medicaid has announced a similar policy, to take effect next year.
What seemed pretty straightforward in 2004 now seems more complicated. “I’d argue that this really is rocket science,” said Mark Chassin, a former New York state health commissioner and since 2008 president of the Joint Commission, which has issued refinements to the 2004 directive. Chassin said he thinks such errors are growing in part because of increased time pressures. Preventing wrong-site surgery also “turns out to be more complicated to eradicate than anybody thought,” he said, because it involves changing the culture of hospitals and getting doctors — who typically prize their autonomy, resist checklists and underestimate their propensity for error — to follow standardized procedures and work in teams.
“It’s disheartening that we haven’t moved the needle on this,” said Peter Pronovost, a prominent safety expert and medical director of the Johns Hopkins Center for Innovation in Quality Patient Care. “I think we made national policy with a relatively superficial understanding of the problem.” Pronovost suggests that doctors’ lip service to the rules, which he calls “ritualized compliance,” may be a key factor. Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout.
Some recent cases: In April an ophthalmologist in Portland, Ore., operated on the wrong eye of a 4-year-old boy. In December 2010, Beth Israel Deaconess Medical Center in Boston reported that neurosurgeons had performed three wrong-site spinal surgeries in a two-month period. And after five wrong-site operations in less than three years, state officials in 2009 ordered that video cameras be installed in the operating rooms of Rhode Island Hospital in Providence, which was fined $150,000.