The authors explain as background information:
Any intervention involving a wrong site, wrong patient or wrong procedure represents an unacceptable surgical complication, classified as a 'never event' by the National Quality Forum.
The Joint Commission set up a Universal Protocol for all ambulatory care facilities, office-based surgical facilities and accredited hospitals.
Regarding the protocol, the researchers wrote:
The Universal Protocol consists of three distinct parts: a preprocedure verification, a surgical site marking and a 'time-out' performed immediately before the surgical procedure. Despite the widespread implementation of the Universal Protocol in recent years, wrong-site surgery continues to pose a significant challenge to patient safety in the United States.
Philip F. Stahel, M.D., and team examined data on a company that provides professional liability insurance for 6,000 practicing doctors in the Colorado area. The insurance has incentives for early reporting of adverse events and assistance for disclosure and resolution with patients and their families.
Between January 2002 and June 2008 there were:
- 27,370 cases of adverse events reported by doctors
- 25 procedures which had been carried out on the wrong patient
- 107 wrong-site procedures
- Five of the patients experienced significant harm from wrong-patient procedures
- 38 suffered damage from wrong-site procedures
- One of the wrong-site procedures resulted in death
Wrong-patient procedures - diagnosis errors contributed to 56% of cases, while communication errors contributed to 100%.
Wrong-site procedures - errors in judgment contributed to 85% of cases, and lack of performing "time-out" contributed to 72%.
They also found that:
- 24% of wrong-patient procedures involved an internal medicine specialist
- 8% of wrong-patient procedures involved family practice or general practice (GP) doctors, or doctors in pathology, urology, obstetrics-gynecology and pediatrics
- 22.4% of wrong-site procedures involved orthopedic surgeons
- 16.8% of wrong-site procedures involved general surgeons
- 12.1% of wrong-site procedures involved anesthetists
The findings from the present study emphasize a continuing and concerning occurrence of wrong-site and wrong-patient procedures in the current era of the Universal Protocol, leading to frequent patient harm and rarely, patient death," the authors write. "Shockingly, non-surgical disciplines equally contribute to patient injuries related to wrong-site procedures.
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.
"Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era - Analysis of a Prospective Database of Physician Self-reported Occurrences"
Philip F. Stahel, MD; Allison L. Sabel, MD, PhD, MPH; Michael S. Victoroff, MD; Jeffrey Varnell, MD; Alan Lembitz, MD; Dennis J. Boyle, MD; Ted J. Clarke, MD; Wade R. Smith, MD; Philip S. Mehler, MD
Arch Surg. 2010;145(10):978-984. doi:10.1001/archsurg.2010.185
Written by Christian Nordqvist