Wrong surgeries a product of poor communication

Mix-ups both inside and outside the operating room lead to procedures performed on the incorrect patient or wrong body part, a new study says.

By Kevin B. O’Reilly — Posted Dec. 11, 2009

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Communication failures such as poor handoff of critical information between surgical team members are the leading cause of surgeries involving the wrong patient, the wrong side, the wrong body part, the wrong implant or the wrong procedure.

Poor communication was the cause of one in five adverse events reported to the Veterans Health Administration system from 2001 to 2006, according to a study published in November's Archives of Surgery (link). Problems during the perioperative timeout process were a root cause of errors more than 15% of the time.

The mistakes appeared to be rare, occurring once every 18,955 surgeries, although a definitive wrong surgery rate could not be established, because some errors go unreported, the study found. A total of 209 adverse events were reported, as were 314 "close calls" in which mistakes were caught before patients were harmed. Of the adverse events, 12% were serious enough to merit root cause analyses.

The VA system in January 2003 adopted a directive for preventing wrong surgeries. The Joint Commission's similar protocol took effect in June 2004. The safety procedures require surgeons and other health professionals to implement a redundant system of checks of the patient's identity, test results, the procedure to be performed and the surgical site. A pre-op timeout for one last check also should be performed.

When those steps are followed, wrong surgeries do not happen, said study co-author James P. Bagian, MD. "We didn't have any adverse events reported where people followed the procedures," said Dr. Bagian, director of the VA's National Center for Patient Safety since 1998.

About half the mistakes occurred in operating rooms, while the other half involved minor surgical procedures performed outside the OR. Studies have estimated that between five and 10 wrong surgeries occur every day in the U.S.

According to the VA study, communication mistakes can become entrenched and overlooked at the timeout stage. "The team may have already fixed in their mind the surgical procedure to be performed."

Dr. Bagian said better adherence to safety protocols is the key to preventing these surgical errors. "The thing that chagrins me is we have [adverse events], and people didn't follow the procedures. It doesn't take any longer to do these things. Instead of chit-chatting about the football game, you ask who the patient is and what the procedure is that you're doing."

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