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Righting Wrongs

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Background

In 1998, the Joint Commission launched a campaign to eliminate wrong-site surgeries, citing an unusual number of cases that year. Five years later little tangible progress had been made, instigating the Commission in 2003 to create a series of universal protocols to target the root causes of wrong-site surgical events. These protocols were only mildly successful, however. Despite their nation-wide implementation, wrong-site surgeries continued to occur, and actually increased in number.

Across the CRICO-insured settings, wrong site surgeries (along with wrong procedure and wrong patient events) represent more than $41 million in incurred losses for 82 cases asserted from January 2003 to June 2008.

More than one-third of those 82 events involved a high-severity injury, and 53 had a loss date (i.e., when the alleged event occurred) of 2003 or later. More procedures, more reporting, and more litigation may be reasons for wrong-site surgeries continuing to make news, but clearly the problem has lost neither its prevalence nor its profundity. And, when wrong site surgeries occur in spite of the concerted effort to eradicate them, the public (including malpractice juries) can become skeptical that the problem is being properly attended to.

Our Recommendation

The insulation generated by repetition and routine in the operating room can have disastrous side effects if physicians and nurses lose sight of why they need those patient safety procedures. Preoperative checklists, timeouts, site signatures, and other measures are here to stay. Unfortunately, when these processes become merely “busy work,” they no longer fulfill their integral function.

Safety systems are in place to prevent against serious error, but are only effective if they are used in the spirit in which they were installed. Completing a checklist is pointless unless it is done properly, i.e., thoroughly. Skimming and never pausing to ask if a condition has truly been satisfied dramatically increases the risk to both the patient and clinical team alike. Recognizing this, caregivers across all specialties should make conscious efforts to ensure that the monotony of an often-repeated task is not overriding their better instincts as they go about their duties.

Lastly, patient safety systems are not fail safe disaster averters. The human phenomena of carelessness and oversight can confound a system’s best efforts to prevent us from making mistakes. As such, it is important to remain vigilant, focus intensely on the task at hand, and make sure that the system is allowed to do its job.


August 1, 2008
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