Most surgical errors are so potentially serious to patients they are classified as “never events” – preventable medical mistakes that should never occur. A study published late last year, however, documents how often serious surgical mistakes are made.
The Agency for Healthcare Research and Quality (AHRQ) is a federal watchdog agency that seeks to improve the nation’s healthcare system and patient safety. It lists a category of surgical never events, which include:
· Surgery on the wrong body part
· Performing surgery on the wrong patient
· Performing the wrong surgical procedure on a patient
The December 2020 issue of Patient Safety, the journal of the agency tasked with improving patient safety in Pennsylvania, published a study that illustrates this never-event occurred hundreds of times over several years (“Wrong-Site Surgery in Pennsylvania During 2015-2019”).
The study was built around wrong-site surgery errors made by Pennsylvania healthcare facilities between 2015 and 2019. Pennsylvania requires these errors to be reported to a government database.
What are Wrong-Site Surgery Errors?
For the purposes of this study, the researchers identified wrong-site surgery errors as:
· Operating on the wrong side of the patient
· Operating on the wrong portion (site) of the patient’s body
· Performing the wrong procedure on the patient
· Operating on the wrong patient
Applying this definition, researchers counted 368 wrong-site surgery errors over the five-year period; an average of more than one serious surgical mistake a week.
Operating on the wrong side of a patient’s body accounted for a little over half of the surgical errors, followed by:
· Operating on wrong site – 32%
· Performing wrong procedure – 13%
The study included both hospitals and ambulatory (outpatient) surgical facilities. It found that:
· 79% of the serious surgical mistakes were made in hospitals
· 21% of the wrong-site surgery errors were made in outpatient surgical centers
Most Common Body Areas That Suffer Wrong-SiteSurgical Errors
The most common parts of the body that suffered wrong-site surgical errors were:
· Patient’s spine – 24%
· Patient’s head or neck area – 17%
· Patient’s lower extremities – 14%
Coverys, a provider of medical malpractice insurance to physicians, released its own study of surgical errors last year (“Surgery Risks: Through the Lens of Medical Malpractice Claims”).
Reviewing medical malpractice lawsuits during roughly the same period – 2014 through 2018 – Coverys found that surgical errors were the second most common cause for medical malpractice claims. And 9% of the patients died as result of the surgical error.
AHRQ has a blueprint for preventing surgical errors. It cites a recognized set of patient verification steps prior to surgery, culminating in the surgical timeout.
Just before operating a team member calls a time out. It includes every surgical team member – and the patient – to verify all important information, such as the patient’s name, the procedure to be performed, and the portion of the body on which is to be performed.
While the study is limited to Pennsylvania, we know surgical errors are made in Missouri and elsewhere. We also know that these never events occur when proper protocols are ignored.
If you or a family member suffered serious harm from a surgical error, contact a personal injury lawyer to discuss your legal options.
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Authored by Gray, Ritter & Graham, P.C., posted in Blog April 9, 2021