Three healthy men had their prostate glands removed. Five people had surgery on the wrong part of their spines. A child underwent an unneeded ear operation after the wrong person was called to go to the operating room.
Despite efforts to end surgical errors, doctors are still reporting operations performed on the wrong body parts and even the wrong people, a recently released study said.
The cases were included in a database of errors Colorado doctors reported to the Colorado Physician Insurance Co., or COPIC, between Jan. 1, 2002, and June 1, 2008, according to the study published in the Archives of Surgery medical journal.
Of the 27,370 incidents in the database, the study found 25 surgeries were performed on the wrong patient and 107 operations on the wrong body part. About one-fourth of those operations inflicted “significant harm” on a patient, according to the study’s investigators, and one person died. That patient suffered acute respiratory failure after a chest tube was placed on the incorrect side, the study said.
“The numbers are pretty shocking,” said the study’s lead author, Dr. Philip Stahel of Denver Health Medical Center and the University of Colorado School of Medicine. Co-authors included COPIC’s CEO and two employees and two consultants of COPIC.
COPIC insured nearly 6,000 doctors during the study period. Researchers didn’t list facilities where the mistakes happened, but Stahel said the results aren’t unique to Colorado.
“It’s a worldwide phenomenon,” he said.
Wrong-site, wrong-patient procedures are called “never events” because such mistakes should never happen.
“It’s like a plane crash. It’s not acceptable to have three planes crash instead of five,” Stahel said. “There should be zero tolerance to these complications.”
Stahel said his study is more accurate than previous studies that looked only at closed insurance claims. Nevertheless, the incidence of wrong-site surgery is probably higher than the study suggests because doctors may be reluctant to report problems, said Dr. Martin Makary of Johns Hopkins University’s surgery department.
“Surgery is a referral business. Reputation is everything,” said Makary, who did not work on the study.
A national standard-setting group for hospitals called The Joint Commission tried to cut the number of “never events” with a universal protocol enacted in 2004. Its rules include marking areas of the body for surgery beforehand and taking a time-out right before surgery so that doctors can affirm what’s about to happen.
Since 1995, the commission has reviewed at least 921 wrong-site procedures reported voluntarily. The numbers have risen sharply over the years, but the group said that may be due to better reporting.
The Colorado study found some errors resulted from laboratory mix-ups before patients got to the operating table. The three healthy men whose prostate glands were removed were the victims of mislabeled lab samples.
Stahel said that shows universal standards should extend to areas outside surgery.
A culture of patient safety needs to be established throughout the medical system, Stahel said.
“We forgot we should be accountable for every individual action on each patient,” he said.
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