You wake up from surgery to find that the doctor operated on the wrong side
of your body and took out your healthy ovary instead of the one with the mass.
It happened to Nadege Neim, a young medical student. Neim’s attorney observed that “If it can happen to a medical student, it can
happen to anyone.”
And it does. Mistakes like this happen about
40 times a week in the U.S.
WSPEs
Surgeries on the wrong side or site, or even
the wrong surgery entirely, are known as WSPEs, which stands for
wrong-site,
wrong-procedure, wrong-patient errors.
The medical establishment calls WSPEs “never” events, meaning they should never happen. They are
considered “avoidable,” but for some reason WSPEs are proving surprisingly
difficult to prevent.
“The number of wrong site surgeries has gone up year after year after year,
so we are becoming concerned about this,” says Dr. Dennis O’Leary, president of a hospital accreditation
organization called the ”Joint Commission.”
ABC reports that “perhaps the most notorious case of wrong
site surgery involved Willie King, who in 1995 went into a Tampa, Fla., hospital
for surgery to amputate one foot badly afflicted by gangrene but had the wrong
foot removed instead.” He wound up with no feet at all.
One
woman with a cancerous lesion on the left side of her vulva had the right
side removed instead.
Someone
else had a cardiac procedure that wasn’t even meant for that patient, but
for another person with a similar name. The parade of horribles goes on and
on.
A Solution? The Universal Protocol
The medical profession has tried putting an end to WSPEs. The Joint
Commission implemented the
Universal Protocol for Preventing Wrong Site, Wrong Procedure and
Wrong Person Surgery in 2004, but it doesn’t seem to be helping — in fact,
the problem may be getting worse, according to
The Washington Post.
The “three principal components of the Universal Protocol include a
preprocedure verification, site marking, and a time out.”
At Stanford Hospital the first component, the “pre-procedure verification,”
includes verifying:
- “relevant documentation” like consent
forms
- “labeled diagnostic tests” and any “required
blood, implants, etc.,” verifying “the correct patient, correct procedure,” and
correct site
- identifying all the items needed for the
procedure and making sure they are available. The medical team should involve
the patient in this process when possible.
The second component of the Universal Protocol, site marking, seems like a
no-brainer: with a permanent marker, a member of the medical team indicates
where the operation should take place. But it is not foolproof. In some cases
there has been confusion about whether the markings indicated the side to
operate on or the side
not to operate on.
The Universal Protocol requires a third component, a time out before all
procedures: “a planned pause before beginning the procedure in order to review
important aspects of the procedure with all involved personnel.” Communications
issues frequently play a role in WSPEs, and time outs are meant to prevent or
resolve those issues.
The
Agency for Healthcare Research and Quality, however, concludes that “many
cases of WSPEs would still occur despite full adherence to the Universal
Protocol. Errors may happen well before the patient reaches the operating room,
a timeout may be rushed or otherwise ineffective, and production pressures may
contribute to errors during the procedure itself.” “Production pressures”
presumably means pressure on doctors to crank out as many procedures as
possible, which is rather horrifying.
One study found that in 72 percent of cases, the Universal Protocol was not followed,
and the researcher speculated that doctors resent the rule.
What Patients Can Do
Since the Universal Protocol has proven not to be a panacea for WSPEs,
patients should take some measures themselves to try to prevent errors. The
Joint Commission recommends that patients “discuss specifically what will be
done…with both the surgeon and the anesthesiologist.” It advises that while they
are still conscious, patients have the site of the surgery marked and have the
surgeon initial it.
Pennsylvania’s
Patient Safety Authority offers a fuller list of
recommendations for patients:
- Don’t be upset if each doctor or nurse asks the same questions about your
identity, procedure, and the side or site of the operation. They are supposed to
individually check with the patient rather than accept what someone else has
written or said.
- Make sure that you know which physician is in charge of your care.
- In addition to your name, give healthcare professionals another identifier,
such as your birth date, to confirm who you are.
- If you are having surgery, make sure that you, your doctor, and your surgeon
all agree and are clear on exactly what will be done.
- Speak up if you have questions or concerns.
- If something does not seem right or if you do not understand something, say
so. Ask for an explanation.
- Ask the doctor or nurse to mark the place that is to be operated upon.
- Make sure you have someone with you that you trust to be your advocate. This
person can ask questions you may not think of and remember important information
you may forget.
- Make sure all health professionals involved in your care know your medical
history.
- Educate yourself about your procedure and don’t be afraid to get a second
opinion.
Personally, next time I or a loved one needs surgery, I plan to stop every
single employee I see and tell them exactly what needs to be done. I’ll talk to
the billing administrator, the receptionist, whoever — better to be known as the
Annoying Patient than miss a chance to prevent a
disaster.
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