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The Pain of Wrong Site Surgery

By Sandra G. Boodman,June 20, 2011

(Page 2 of 3)

Stahel was lead author of a 2010 study of 132 wrong-site and wrong-patient cases reported by doctors to a large malpractice insurer in Colorado between 2002 and 2008, one-third of which resulted in death or serious injury. Among them were three men who underwent prostate cancer surgery although they were cancer-free. In 72 percent of cases there was no timeout.

Stahel says many doctors resent the rules, even though orthopedists have a 25 percent chance of making a wrong-site error during their career, according to the American Academy of Orthopaedic Surgeons, which launched a voluntary “Sign Your Site” campaign in 1997.

“It’s very frustrating,” said surgeon John Clarke, clinical director of the Pennsylvania Patient Safety Authority. “If you can’t solve the wrong-site-surgery problem, what can you solve?”

Ritualized compliance

The legal system typically offers little recourse: One study found that only a third of wrong-site cases result in a malpractice suit. Stahel’s team found that the average payment was less than $81,000 in cases resulting in a lawsuit and $47,000 in those resolved without legal action.

While some wrong-site errors inflict little or no injury, either because they are corrected early or did not involve major surgery, others are devastating. Last year a jury returned a $20 million negligence verdict against Arkansas Children’s Hospital for surgery on the wrong side of the brain of a 15-year-old boy who was left psychotic and severely brain-damaged. Testimony showed that the error was not disclosed to his parents for more than a year. The hospital issued a statement saying it deeply regretted the error and had “redoubled our efforts to prevent” a recurrence.

“I felt violated,” said Lexie Fincher, 39, of Fredericksburg, whose Virginia surgeon in 2008 failed to mark the site of a benign tumor, then misinterpreted her MRI scan and operated on the wrong part of her shoulder, causing continued pain and leaving a scar. “It was absolutely avoidable.”

Clarke said researchers have discovered that the way a timeout is done and where it is performed make a difference, details that the protocol initially did not specify. Doctors who verify the site and procedure with patients before they are wheeled into surgery are less likely to make a mistake, as are those who explictly ask everyone on the team to speak up if they have concerns. “There’s a big difference between hospitals that take care of patients and those that take care of doctors,” Clarke said. “The staff needs to believe the hospital will back them against even the biggest surgeon.”

‘They will all die’

Many experts say that medicine needs standardized rules similar to those in aviation, which bar takeoff until a pilot and co-pilot complete a prescribed checklist without interruption. Airlines have a vested interest in a culture of safety that Stahel says medicine lacks. In surgery “sometimes people say, ‘Well, this isn’t quite right, but someone else will address it.’ In aviation they don’t do that, because the plane will crash and they will all die,” he said.

“Health care has far too little accountability for results. . . . All the pressures are on the side of production; that’s how you get paid,” said Hopkins’s Pronovost, who adds that increased pressure to turn over operating rooms quickly has trumped patient safety, increasing the chance of error.

Kenneth W. Kizer, who coined the term “never event” nearly a decade ago when he headed the National Quality Forum, a leading patient safety organization, said he believes reducing the number of errors will require tougher reporting rules and increased transparency. Kizer, California’s former chief health officer, advocates mandatory reporting of wrong-site errors to a federal agency so cases can be investigated and the results publicly reported.

“How can you say these things should not be reported?” asked Kizer, director of the Institute for Population Health Improvement at the University of California at Davis. “These are the health-care equivalent” of plane crashes.

Shepard Hurwitz, director of the American Board of Orthopaedic Surgery, said he believes withholding payment for errors may prod hospitals fearful of offending their medical staffs to enforce safety rules and take action against recalcitrant doctors. “I think before it was thought to be the cost of doing business,” Hurwitz said. “I think the first time it happens, the person should be taken out of circulation until they understand what they did wrong. And if it happens again, they’re finished.”

One surgeon’s mea culpa

Hand surgeon David C. Ring was in his office at Massachusetts General Hospital dictating notes when the sickening realization hit him: The carpal tunnel release he had just completed was the wrong surgery.

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