Pa. Hospitals Report Surgery Errors Caught Every Day But Many Occur

June 28, 2007

Pennsylvania hospitals reported making serious mistakes in the operating room — using the wrong procedure, operating on the wrong body part or even the wrong patient — 174 times during a 21/2 year period, according to a report released by the state’s patient-safety agency.

The state Patient Safety Authority, which collects data on medical errors and advises health care facilities on how to improve their practices, issued its report on so-called “wrong-site” surgeries as part of an effort to eliminate them.

Between June 2004 and December 2006, the time period the authority studied, it also received reports of 253 incidents that could have resulted in wrong-site errors but were corrected before an operation began.

“Every other day in Pennsylvania, we have a report of a wrong-site surgery being caught either before or after the start of the operation,” said Dr. Stan Smullens, the authority’s vice chairman and chief medical officer at Jefferson Health System in Radnor.

Of the surgeries involving serious mistakes, 69 percent were on the wrong side of the body, 14 percent were on the wrong body part, 9 percent were the wrong procedure and 8 percent were on the wrong patient.

One example cited in the report involved a patient who was supposed to have his right Achilles tendon repaired along with a joint in his left hand.

Although the correct body parts were marked when the patient was lying on his back, he was turned on his stomach for the surgery. Because the markings were hidden, the doctor erroneously operated on the patient’s left Achilles tendon and right hand instead, the report said.

The report attributed the mishaps to factors such as surgeons and nurses failing to review what needs to be done before cutting; not double-checking where surgical sites have been marked; and improperly positioning the patient on the operating table.

It is difficult to measure how Pennsylvania compares with other states because not all require hospitals to report medical errors, and the reporting criteria can vary among those that do, said Mike Doering, the authority’s interim executive director.

Over the summer, the authority plans to visit selected hospitals and gather information on strategies they are using to prevent wrong-site surgeries, Doering said. It will use that information to provide guidance to all hospitals, he said.

“We have a good idea of what works and what doesn’t work, but we want to go observe,” Doering said.

Dr. Anthony J. Ardire of the Lehigh Valley Health System in Allentown said his hospital has eliminated errors involving surgeries and other procedures, such as colonoscopies, since it instituted several new policies 18 months ago. One new rule requires at least two staff members to conduct preoperative reviews to ensure that a surgery is performed properly.

“A resident or a physician has to make a decision that this isn’t going to happen to their patient,” Ardire said. “They really have to say, ‘We’re not going to take shortcuts. We’re going to do it right.”’

Although the patient safety authority’s efforts to advise hospitals are critical, the agency does not have the power to force hospitals to follow its recommendations, said RoseMarie B. Greco, director of the Governor’s Office of Health Care Reform.

“It is hospital leadership who has that authority, and government who has the responsibility to ensure that authority is being used to protect patients,” Greco said.


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