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Frequent Occurrences of Wrong-Site Surgery have Implications for the Medical Field

It’s every patient’s nightmare – being admitted to a hospital for routine surgery and wading through a drug-induced fog hours later only to find that doctor’s have operated on the wrong site.Patients, who only wanted a good outcome, are left to figure out how to deal with their unexpected injuries and with a medical malpractice claim they never expected to have to pursue. Apparently, wrong-site surgeries have become a reality for some patients, occurring more often than previously thought. According to the Joint Commission, "National rates of wrong-site surgeries-which include wrong procedure, wrong side and wrong patient-can reach as high as 40 incidences a week." Medical malpractice attorneys agree that the culprit, as is usually the case in institutional settings, is a lack of communication.

The operating room becomes a hum of noise; from the incessant sound of machines to the voices of nurses and doctors battling time and sometimes even each other. The Las Vegas Review-Journal cites issues with pre-operation prep (such as unapproved abbreviations on charts and illegible handwriting) and scheduling processes as added distractions. In light of this, it’s easy to see how some details, such as the purpose of the operation, could get lost in translation. When this occurs, patient safety is put at risk and hospitals, doctors and nurses expose themselves to significant liability for medical malpractice.

Hospitals are exploring various ways to combat wrong-site surgeries, however, and one of the most popular tactics seems to be the institution of a “time out” of sorts – calling for all key participants in the OR to take a step back and assess their plan. This program, designed by the Joint Commission Center for Transforming Health Care and instituted in 2003, works by essentially creating a script for staff to follow, says the Review-Journal. Throughout the course of this “Universal Protocol” script, doctors are required to 1.) Complete a pre-operative verification. 2.) Marking of the operative site and 3.) A time out immediately before starting the procedure.

The script’s first line? “Let’s start with a time out.”

With everyone’s focus on the patient, the staff runs through a checklist to make sure everything is in order. They even go so far as to physically identify the site where the surgery is to be completed on the patient’s body.Everyone on the team must acknowledge their comprehension and express any concerns before the process can resume.

Unfortunately, despite a degree of success for the program, medical errors are still rampant. Just this past April ABC News reports , a surgeon “lost her sense of direction” and performed corrective surgery on the wrong eyeof a four-year-old boy and then, realizing his error, quickly operated on the correct eye, without consulting the child’s parents. Now the boy’s eye may be permanently damaged. The Universal Protocol was in place, but while prepping him for surgery a nurse mistakenly covered the pre-op mark that had been made on the eye that needed correction.

I believe this is proof that while the time-out method is good in theory, it is by no means a fail-safe. Quite frankly, no matter the caution exerted, operations are simply subject to human error and we must continue exploring many and varied solutions.