Medical Errors Persist Despite Safeguards
Errors in Diagnosis, Communication, Judgment Blamed for Wrong-Patient, Wrong-Site Medical Mistakes
Oct. 18, 2010 -- Serious medical mistakes, like performing a medical procedure on the wrong person or wrong site, continue to occur despite recently implemented preventive measures.
A new study shows 25 cases of procedures performed on the wrong person and 107 cases of procedures performed on the wrong site occurred in a 5 1/2-year period in Colorado, resulting in at least one death and several complications.
In 2004, the Joint Commission, which regulates medical professions, introduced a Universal Protocol for all hospitals and outpatient facilities that perform medical procedures. The protocol is designed to reduce medical errors and consists of three parts: a pre-procedure verification, a surgical site marking, and a "time-out" performed immediately before the surgical procedure. During the time-out members of the team performing the procedure confirm the identification of the patient, the type of procedure, and the procedure site.
“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,” write researcher Philip F. Stahel, MD, of the University of Colorado, and colleagues in the Archives of Surgery. “Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures.”
Better Planning, Prevention Needed
In the study, researchers examined data collected by an insurance company that provided liability coverage to 6,000 doctors in Colorado from Jan. 1, 2002, to June 1, 2008.
During the study period, 25 wrong-patient and 107 wrong-site procedures were reported. Significant harm occurred as a result in 20% of wrong-patient medical errors and in 35.5% of wrong-site procedures. One person died as a result of a wrong-site procedure.
Researchers found the main factors behind wrong-patient medical mistakes were errors in diagnosis (56%) and errors in communication (100%).
Errors in judgment contributed to 85% of wrong-site medical errors and the lack of performing a "time out" before starting the surgical procedure was cited as the cause in 72% of these mistakes.
Researchers say nonsurgical specialties, such as general or family practice, internal medicine, emergency medicine, or pediatrics, were as much to blame as surgeons and contributed equally to complications arising from wrong-site medical mistakes.
“Inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome," write the researchers. "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.”