String of Lapses Leads to Wrong-Site Surgery

In the medical community they are called “never events”--mistakes that are so basic there is absolutely no excuse for them ever being committed. The prototype “never event” is a wrong-site surgery. This refers to situations where a surgeon performs the wrong operation, on the wrong part of the body, or on the wrong patient. Amazingly, these egregious errors are not nearly as rare as some might suspect. They occur far too often, usually when medical professionals cut corners and engage in lax safety protocols.

Just last month, a story from General Surgery News explained how one young boy was forced to undergo a second operation on his tongue because of one of these unacceptable medical errors. The report noted that that the doctor performed the wrong operation on the tongue to remove a growth. When asked about the error the doctor pointed fingers at others, suggesting that his staff should have told him to perform a “time out”--a waiting period to check on the basics before proceeding with an operation. Also, he admitted not to having seen the patient before the operation.

The author of the story explained the string of unanswered questions about the situation: “Who obtained consent from the child’s mother? What did the consent form say? Didn’t the circulating nurse or anyone else look at the form to verify what operation was to be done? Don’t the nurses enforce the time out rule? What was the anesthesiologist doing?”

Sadly, this is just one of many examples of medical teams making a string of errors and forcing the patient--in this case a young boy--to face an unnecessary surgery.

The surprising frequency of these medical errors has long-been discussed among patient safety advocates. A Washington Post last year mentioned how a Joint Commission report claimed that wrong-site surgeries occur 40 times every week across the country. We are not talking about a once a year problem. Hundreds and hundreds of patients fall victim with varying consequences.

While reliable data on these errors is hard to come by, many suggest that the problem is actually increasing. One reason may be time pressures. The story also argues that one key issue is that medical professional fail to use safety standards that are known to limit the errors. It notes that fixing the problem “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.”

Of course those patients harmed by these medical errors are able to use the civil justice system to ensure the medical professionals are held accountable and redress is provided. As the lack of improvement over the years shows, changing practices to prevent repeat errors is not easy. An obvious component to the effort is ensuring that doctors are not allowed to sweep the problem under the rug. To learn more about these issues in our area, consider contacting the malpractice lawyers at our firm.