A 76-year-old New York man with kidney disease was scheduled to have surgery to remove his diseased kidney (both of his kidneys were diseased but only the more diseased kidney was to be removed). For some unexplained reason, his surgeon removed the wrong kidney (his less diseased kidney). Realizing his mistake, the surgeon then removed the other, more diseased kidney. The man now needs to be on dialysis due to the medical mistake.
The wrong site surgery took place at Mt. Sinai Hospital in New York, which has publically apologized for the medical error. The man reportedly forgave his surgeon for performing the wrong site surgery. A spokeswoman for Mt. Sinai Hospital stated on behalf of the hospital, “The patient states that the surgeon in question helped him overcome bladder cancer in the past, and despite this error, says he has ‘enormous faith’ in the doctor.”
Wrong Site Surgery Statistics
It is estimated that surgery performed on the wrong side of the body, the wrong site, or the wrong patient occur at a national rate as high as 40 times every week. In 2010, wrong site surgery was the third most common type of sentinel event reported to The Joint Commission Center for Transforming Healthcare. It is estimated that in 39% of the wrong site surgery cases, the medical errors occurred during the scheduling process that increased the risk of wrong site surgery. Eight hospitals and ambulatory surgery centers working with The Joint Commission Center for Transforming Healthcare reported that addressing documentation and verification issues in the preoperative holding areas decreased the percentage of wrong site surgery cases with risks from a baseline of 52% to 19%, and the incidence of cases containing more than one risk decreased by 72%.
Root Causes For Risk Of Wrong Site Surgery
Booking documents not verified by office schedulers
Schedulers accept verbal requests for surgical bookings instead of written documents
Unapproved abbreviations, cross-outs, and illegible handwriting used on booking form
Missing consent, history and physical, or surgeon’s orders at time of booking
Primary documents (consent, history and physical, surgeon’s booking orders, operating room schedule)
missing, inconsistent or incorrect
Paperwork problems identified in pre-op but resolved in a different location
Inconsistent use of site marking protocol
Someone other than surgeon marks site
Surgeon does not mark site in pre-op/holding
Site mark made with non-approved surgical site marker
Stickers used in lieu of marking the skin
Inconsistent site marks used by physicians
Inconsistent or absent Time Out process for regional blocks
Rushing during patient verification
Alternate site marking process does not exist or is not used
Inadequate patient verification by team
Lack of intraoperative site verification when multiple procedures performed by the same provider
Ineffective hand-off communication or briefing process
Primary documentation not used to verify patient, procedure, site and side
Site mark(s) removed during prep or covered by surgical draping
Distractions and rushing during Time Out
Time Out process occurs before all staff are ready or before prep and drape occurs
Time Out performed without full participation
Time Outs do not occur when there are multiple procedures performed by multiple providers
in a single operative case
Senior leadership is not actively engaged
Inconsistent organizational focus on patient safety
Staff is passive or not empowered to speak up
Policy changes made with inadequate or inconsistent staff education
Marketplace competition and pressure to increase surgical volume leads to
shortcuts and variation in practice
If you or a loved one were the victim of wrong site surgery in the United States, you should promptly seek the advice of a local medical malpractice attorney in your state to learn about your rights and responsibilities in bringing a claim for your injuries and the harms you suffered.
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