| Surgery is stressful enough without having to worry | | | | confirming the correct surgical site is marked at the |
| whether the surgeon is going to operate on the | | | | start and at the time the surgery begins, or the right |
| correct body part. A wrong-site surgery occurs when | | | | number of sponges and instruments are on the table |
| the doctor mistakenly performs a medical procedure | | | | and of course, at the end of the procedure.� |
| on the incorrect organ or wrong side of the body. | | | | In addition to WHO, the Joint Commission on |
| Although some of these sorts of medical mistakes | | | | Accreditation of Healthcare Organizations (JCAHO or |
| may be corrected after the fact, they are often | | | | Joint Commission), the biggest and oldest U.S. |
| irreversible, such as with an amputation or removal of | | | | professional organization setting healthcare safety |
| an internal organ. | | | | standards and accrediting medical facilities, has |
| Recent New England Example | | | | developed, with input from major medical |
| The Rhode Island Department of Health on | | | | associations, professionals and the public, the |
| November 2 publicly reprimanded Providence's Rhode | | | | Universal Protocol for Preventing Wrong Site, Wrong |
| Island Hospital, affiliated with Brown University, for an | | | | Procedure and Wrong Person Surgery (Universal |
| October surgery on a patient's wrong finger. The | | | | Protocol). Widely endorsed, the protocol has three |
| Health Department found that the hospital did not | | | | main parts: |
| follow its own safety procedures governing proper | | | | - Presurgury verification of documents |
| surgical-site marking and planned timeout from the | | | | - Clear and unambiguous surgical-site marking |
| surgical process to check that nothing was amiss. | | | | - Timeout immediately before surgery |
| For only the second time ever, the Rhode Island | | | | The timeout is used to confirm the right surgical |
| Department of Health imposed a fine on a hospital | | | | procedure, surgical site and patient identity. All |
| ($150,000). The first was on the same institution in | | | | members of the surgical team are urged to verbalize |
| 2007 for another wrong-site surgery. In addition to | | | | during the timeout questions or confusion about the |
| the current incident, this hospital has had four other | | | | surgery the team is about to perform. |
| wrong-site surgeries since 2006: three brain surgeries | | | | The jury is still out as to the long-term effectiveness |
| and one for cleft palate. | | | | of the Universal Protocol in preventing surgical-site |
| In addition to the fine, regulators required the hospital | | | | errors. Its use is required in JCAHO-accredited |
| to install video and audio equipment in operating | | | | facilities and its basic elements have been adopted |
| rooms and mandated observation for a year of each | | | | and enhanced by many state governments, |
| surgical procedure by a medical professional with | | | | professional organizations and medical institutions in |
| special training in safe surgery and implementation of | | | | developing their own protocols. |
| a statewide surgical safety protocol that was | | | | New York Surgical Errors |
| developed by the World Health Organization (WHO). | | | | The problem of wrong-site surgery is also alive and |
| Hospital President and Chief Executive Officer | | | | well in New York. For example, from 2003 to 2005, |
| Timothy Babineau, M.D., acknowledges the most | | | | 347 wrong-site, wrong-patient or wrong-procedure |
| recent incident on the hospital's Web site, pledging | | | | events were reported through the New York Patient |
| ongoing safety improvement. He estimates that | | | | Occurrence and Tracking System (NYPORTS), the |
| "wrong site surgical errors continue to occur at | | | | mandatory state medical-error reporting system. |
| hospitals all over this country at a rate of nearly 40 | | | | After reviewing the Universal Protocol and other |
| per week." | | | | resources, New York developed its own New York |
| Root Causes and Prevention | | | | State Surgical and Invasive Procedure Protocol |
| Researchers have found wrong-site surgeries to be | | | | (NYSSIPP). NYSSIPP is the official and required |
| symptomatic of both poor communication among | | | | standard of care for most surgical procedures in New |
| involved medical professionals, the patient and family | | | | York. It includes and enhances the three basic |
| and of inadequate teamwork among the doctors, | | | | elements of the Universal Protocol -- verification, |
| nurses and other medical professionals on the surgical | | | | marking and timeout -- plus standards for scheduling, |
| team. Other contributing factors include fatigue, | | | | consent, disagreement resolution and compliance |
| stress, complexity of our healthcare system, | | | | oversight. NYSSIPP especially encourages active |
| inadequate institutional information management | | | | communication among all members of the surgical |
| systems, hurriedness and inexperience. | | | | team, particularly during the scheduled preoperative |
| WHO developed an international pilot program that | | | | timeout. |
| introduced a Surgical Patient Safety Checklist and | | | | New York Medical Malpractice |
| found that when followed, use of the protocol | | | | A New York patient who is the unfortunate victim of |
| resulted in nearly one third significantly fewer deaths | | | | wrong-site surgery should consult with an |
| and complications among a diverse adult patient | | | | experienced medical malpractice attorney to discuss |
| population undergoing non-cardiac surgery. The pilot | | | | possible legal remedies. In order to be successful on a |
| program researchers, who are part of the WHO | | | | claim for medical malpractice in New York, a plaintiff |
| Safe Surgery Saves Lives Study Group, published | | | | must prove that the doctor or other medical |
| their findings in the January 14, 2009 edition of the | | | | professional departed from an accepted standard of |
| New England Journal of Medicine. | | | | practice, and that the deviation proximately caused |
| Essentially, the WHO protocol has evolved into a | | | | the complained-of injury. Other possible legal claims |
| 19-item checklist that contains a series of points | | | | could be general negligence, gross negligence, |
| during all surgical procedures that a surgical team | | | | wrongful death, lack of consent or reckless |
| goes through and when doing so, the team must | | | | indifference. In a New York wrong-site surgery case, |
| confirm they had completed each step in the | | | | a likely issue will be whether the surgeon and his or |
| protocol. For example, the study identified three | | | | her team complied with the requirements of the |
| critical points during a surgical procedure: before | | | | Universal Protocol and the NYSSIPP, and whether |
| anesthesia, just before incision, and before the | | | | deviation from the standards in those protocols |
| patient leaves the operating room.� A | | | | caused injury. |
| significant requirement of this protocol is that a | | | | A personal injury lawyer should be contacted as early |
| member of the team must verbally confirm that each | | | | as possible so as not to miss any deadlines for giving |
| step of infection control, anesthesia safety and other | | | | notice or bringing a lawsuit. |
| important considerations�are met, such as | | | | |