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The Pain of Wrong Site Surgery

June 20, 2011

When the president of the Joint Commission, the Chicago-based group that

accredits the nation’s hospitals, unveiled mandatory rules to prevent operations

on the wrong patient or body part, he did not mince words.

“This is not quite ‘Dick and Jane,’ but it’s pretty close,” surgeon Dennis O’Leary

declared in a 2004 interview about the “universal protocol” to prevent wrong-

site surgery. These rules require preoperative verification of important details,

marking of the surgical site and a timeout to confirm everything just before the

procedure starts.

Mistakes such as amputating the wrong leg, performing the wrong operation or

removing a kidney from the wrong patient can often be prevented by what

O’Leary called “very simple stuff”: ensuring that an X-ray isn’t flipped and that

the right patient is on the table, for example. Such errors are considered so

egregious and avoidable that they are classified as “never events” because they

should never happen.

But seven years later, some researchers and patient safety experts say the

problem of wrong-site surgery has not improved and may be getting worse,

although spotty reporting makes conclusions difficult. Based on state data, Joint

Commission officials estimate that wrong-site surgery occurs 40 times a week in

U.S. hospitals and clinics. Last year 93 cases were reported to the accrediting

organization, compared with 49 in 2004. Reporting to the commission is

voluntary and confidential — to encourage doctors and hospitals to come

forward and to make improvements, officials say. About half the states,

including Virginia, do not require reporting. In two states that track and

intensively study these errors, 48 cases were reported in Minnesota last year, up

from 44 in 2009; Pennsylvania has averaged about 64 cases for the past few

years.

Attention to the problem comes at a time of increased focus on the broader

issue of medical errors, which a recent Health Affairs study found affected one-

third of hospital patients. The federal government recently rolled out its

Partnership for Patients program aimed at reducing medical mistakes.

Medicare requires reporting and does not pay for wrong-site surgery, and many

insurers have followed suit. Medicaid has announced a similar policy, to take

effect next year.

What seemed pretty straightforward in

2004 now seems more complicated. “I’d

argue that this really is rocket science,”

said Mark Chassin, a former New York

state health commissioner and since

2008 president of the Joint Commission,

which has issued refinements to the 2004

directive. Chassin said he thinks such

errors are growing in part because of

increased time pressures. Preventing

wrong-site surgery also “turns out to be

more complicated to eradicate than

anybody thought,” he said, because it

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.

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“It’s disheartening that we haven’t moved the needle on this,” said Peter

Pronovost, a prominent safety expert and medical director of the Johns

Hopkins Center for Innovation in Quality Patient Care. “I think we made

national policy with a relatively superficial understanding of the problem.”

Pronovost suggests that doctors’ lip service to the rules, which he calls

“ritualized compliance,” may be a key factor. Studies of wrong-site errors have

consistently revealed a failure by physicians to participate in a timeout.

Some recent cases: In April an ophthalmologist in Portland, Ore., operated on

the wrong eye of a 4-year-old boy. In December 2010, Beth Israel Deaconess

Medical Center in Boston reported that neurosurgeons had performed three

wrong-site spinal surgeries in a two-month period. And after five wrong-site

operations in less than three years, state officials in 2009 ordered that video

cameras be installed in the operating rooms of Rhode Island Hospital in

Providence, which was fined $150,000.

Wrong-site mistakes have multiple causes, experts say: mixing up the left and

right sides; operating on a patient who was accidentally given test results

belonging to someone else; marking the incorrect vertebrae in spinal surgery;

neglecting to mark the site at all. Some occur even though a member of the

surgical team thinks something might be wrong but fails to speak up, fearful of

slowing the process or challenging the surgeon in charge.

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Reported cases are “clearly the tip of the iceberg,” said Philip F. Stahel, director

of orthopedic surgery at Denver Health Medical Center.

Stahel was lead author of a 2010 study of 132 wrong-site and wrong-patient

cases reported by doctors to a large malpractice insurer in Colorado between

2002 and 2008, one-third of which resulted in death or serious injury. Among

them were three men who underwent prostate cancer surgery although they

were cancer-free. In 72 percent of cases there was no timeout.

Stahel says many doctors resent the rules, even though orthopedists have a 25

percent chance of making a wrong-site error during their career, according to

the American Academy of Orthopaedic Surgeons, which launched a voluntary

“Sign Your Site” campaign in 1997.

“It’s very frustrating,” said surgeon John Clarke, clinical director of the

Pennsylvania Patient Safety Authority. “If you can’t solve the wrong-site-

surgery problem, what can you solve?”

Ritualized compliance

The legal system typically offers little recourse: One study found that only a

third of wrong-site cases result in a malpractice suit. Stahel’s team found that

the average payment was less than $81,000 in cases resulting in a lawsuit and

$47,000 in those resolved without legal action.

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While some wrong-site errors inflict little or no injury, either because they are

corrected early or did not involve major surgery, others are devastating. Last

year a jury returned a $20 million negligence verdict against Arkansas

Children’s Hospital for surgery on the wrong side of the brain of a 15-year-old

boy who was left psychotic and severely brain-damaged. Testimony showed that

the error was not disclosed to his parents for more than a year. The hospital

issued a statement saying it deeply regretted the error and had “redoubled our

efforts to prevent” a recurrence.

“I felt violated,” said Lexie Fincher, 39, of Fredericksburg, whose Virginia

surgeon in 2008 failed to mark the site of a benign tumor, then misinterpreted

her MRI scan and operated on the wrong part of her shoulder, causing

continued pain and leaving a scar. “It was absolutely avoidable.”

Clarke said researchers have discovered that the way a timeout is done and

where it is performed make a difference, details that the protocol initially did

not specify. Doctors who verify the site and procedure with patients before they

are wheeled into surgery are less likely to make a mistake, as are those who

explictly ask everyone on the team to speak up if they have concerns. “There’s a

big difference between hospitals that take care of patients and those that take

care of doctors,” Clarke said. “The staff needs to believe the hospital will back

them against even the biggest surgeon.”

‘They will all die’

Many experts say that medicine needs standardized rules similar to those in

aviation, which bar takeoff until a pilot and co-pilot complete a prescribed

checklist without interruption. Airlines have a vested interest in a culture of

safety that Stahel says medicine lacks. In surgery “sometimes people say, ‘Well,

this isn’t quite right, but someone else will address it.’ In aviation they don’t do

that, because the plane will crash and they will all die,” he said.

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“Health care has far too little accountability for results. . . . All the pressures are

on the side of production; that’s how you get paid,” said Hopkins’s Pronovost,

who adds that increased pressure to turn over operating rooms quickly has

trumped patient safety, increasing the chance of error.

Kenneth W. Kizer, who coined the term “never event” nearly a decade ago when

he headed the National Quality Forum, a leading patient safety organization,

said he believes reducing the number of errors will require tougher reporting

rules and increased transparency. Kizer, California’s former chief health officer,

advocates mandatory reporting of wrong-site errors to a federal agency so cases

can be investigated and the results publicly reported.

“How can you say these things should not be reported?” asked Kizer, director of

the Institute for Population Health Improvement at the University of California

at Davis. “These are the health-care equivalent” of plane crashes.

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Shepard Hurwitz, director of the American Board of Orthopaedic Surgery, said

he believes withholding payment for errors may prod hospitals fearful of

offending their medical staffs to enforce safety rules and take action against

recalcitrant doctors. “I think before it was thought to be the cost of doing

business,” Hurwitz said. “I think the first time it happens, the person should be

taken out of circulation until they understand what they did wrong. And if it

happens again, they’re finished.”

One surgeon’s mea culpa

Hand surgeon David C. Ring was in his office at Massachusetts General

Hospital dictating notes when the sickening realization hit him: The carpal

tunnel release he had just completed was the wrong surgery.

“It was the worst feeling of my life: The ground literally falls beneath you,” Ring

recalled in an interview. He returned to the operating room and informed the

staff, then apologized to the 65-year-old patient, who spoke only Spanish and

agreed to let him perform the correct surgery, a trigger finger release.

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Several factors contributed to Ring’s mistake, which he wrote about last year in

the New England Journal of Medicine; chief among them was the failure to

perform a timeout because of various distractions.

The patient did not file a lawsuit, and Ring said the hospital paid her a modest

amount in compensation. As a result of the case, safety monitors were assigned

to the hospital’s operating rooms, and nurses were instructed not to hand the

knife to the surgeon until the timeout is completed.

“I was an advocate before, but now I really believe in safety systems,” said Ring,

who speaks to medical groups and says he still “tears up” when discussing the

error. “I don’t want any patient or doctor to feel like I felt.”

This story was produced through a collaboration between The Post and Kaiser

Health News. KHN is a news service of the Kaiser Family Foundation, a

nonpartisan health-care policy research organization unaffiliated with Kaiser

Permanente.

By Sandra G. Boodman

Surgeon holding scalpel, close-up, low angle view (gel effect) (Richard Price/GETTY IMAGES)

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Sandra G. Boodman Sandra G. Boodman, who was a Washington Post staff writer for more than 30 years, created the Medical Mysteries column.

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