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Researchers find that inadequate communication between health care providers is a frequent contributing factor for wrong-site surgery.


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6/13/2015
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Numerous surveys and studies show that major errors during surgery are not common, but mistakes that could have been prevented still happen in hospitals throughout the United States. 

A new study shows that in about 1 in 100,000 surgeries, physicians make a wrong site error — for example, they operate on the wrong side of a person's body, or sometimes even on the wrong person.

“And in 1 out of every 10,000 procedures, doctors leave something (such as a medical sponge) in the patient's body, the researchers found. Poor communication among medical staff is the root cause of many of these mistakes, the researchers said in their article, published online Wednesday (June 10) in the journal JAMA Surgery,” according to Fox news.

How should these mistakes be prevented?

Susanne Hempel, co-director of the Evidence-based Practice Center at the RAND Corporation, a nonprofit global policy think tank headquartered in California led the study. She said while these mistakes are rare, it is important to have a plan of action in place to prevent them.

How was the study conducted?

Hempel and her team led the review for the U.S. Veterans Affairs National Center for Patient Safety, to analyze the state of the evidence 10 years after the introduction of the Universal Protocol, a concerted effort to upgrade surgical safety.

“In the review, the researchers looked at 138 studies, published from 2004 to 2014, that reported on at least one of three types of never events: wrong-site surgery, leaving an item behind in a person during surgery, and surgical fires,” according to Fox news.

The researchers realized that the frequency of these events varied depending on the type of surgery being performed and the data collection methods used in the studies. For example, according to a report of eye doctor claims and state reporting records, there were 0.5 wrong-site events per 10,000 procedures.

“But according to a survey of eye doctors who operate on people with ‘lazy eye’, there were 4 wrong-site events per 10,000 procedures,” according to Fox.

The studies show that there is generally a unique set of factors and circumstances behind a rare mistake. Hempel found that inadequate communication between health care providers was a frequent contributing factor; in particular, for wrong-site surgery.

Hempel said, “This included miscommunication among staff, missing information that should have been available to the operating-room staff and surgical team members not speaking up, or not listening to suspicions.”

What should the remedies be? The experts said there need to be better tracking of rare mistakes, so that doctors can create better tools and techniques to avoid them in the long run.

Physicians also may need to test different methods, such as tracking mistakes that are near misses, which are potential events that were averted before patients were hurt or died.

 



Category: Surgical Mistakes

Gerry Oginski
NY Medical Malpractice & Personal Injury Trial Lawyer

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