Despite a protocol instituted by the Joint Committee to prevent wrong-site and wrong-patient medical errors, a new study shows that these errors are still taking place. The Universal Protocol requires clinicians to perform several safeguarding steps, including preoperative verification, marking of the surgical site, and a ‘time out’ immediately before surgery.
The study, published in the Archives of Surgery, analyzed an insurance database of 6,000 physicians in Colorado to determine the frequency and severity of these errors. The researchers found that there were 27,370 self-reported adverse events between 2002 and 2008. Of those, 25 procedures were performed on the wrong patient, and 107 were wrong-site procedures. Five patients experienced significant harm from the wrong-patient procedures, and 38 were damaged by wrong-site procedures. One patient died due to a wrong-site procedure.
The main causes of the wrong-patient procedures were errors in diagnosis (56%) and communication errors (100%), the researchers determined. Root causes in the wrong-site procedures were errors in judgment (85%) and failure to perform a ‘time out’ prior to surgery (72%).
The researchers also determined that “nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.” Internal medicine specialist were involved in 24% of wrong-patient errors, and 8% involved general practitioners, or doctors specializing in pathology, urology, obstetrics-gynecology and pediatrics.
The researchers concluded, “inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome. On the basis of these findings, a strict adherence to the Universal Protocol must be expanded to non-surgical specialties to achieve a zero-tolerance philosophy for these preventable incidents.”