Northeast Florida Medicine
Vol. 66, No. 1 2015
21
CME
The objective of the study was to determine the frequency,
root cause and outcome of WSPE procedures. The research-
ers analyzed a prospective physician insurance database and
de-identified cases were screened. The database contained
27,370 self-reported adverse occurrences. Dr. Stahel and his
cohorts generated descriptive statistics and examined the num-
ber of adverse events reported per year, and the root causes and
occurrence-related patient outcomes. They reported that: “A
total of 25 wrong-patient and 107 wrong-site procedures were
identifiedduringthestudyperiod.Significantharmwasinflicted
in five wrong-patient procedures (20 percent) and 38 wrong-
site procedures (35.5 percent). One patient died secondary to
a wrong-site procedure (0.9 percent). The main root causes
leading towrong-patient procedureswere errors indiagnosis (56
percent) and errors in communication (100 percent), whereas
wrong-site occurrences were related to errors in judgment (85
percent) and the lack of performing a ‘time-out’” (72 percent).
4
Hospitals and surgical centers permit non-compliance
with “Universal Protocol,” albeit the American Academy of
Orthopedic Surgeons states that orthopedic surgeons have a
25 percent chance of making a wrong-site error during their
career.
5
The Academy launched a voluntary “Sign Your Site”
campaign in 1997, putting up billboards across the country
in an attempt to educate patients. The billboard at O’Hare
Airport inChicago, for example, had a handholding a Sharpie
marker and the caption indicated that the marker may be the
most important tool your surgeon uses.
The problem is certainly not isolated to the US –as indi-
cated– in Great Britain’s “Health Reporter” on Thursday,
December 12, 2013 which reported that, “Surgeons at a
National Health Service hospital carried out heart surgery on
the wrong patient, it was revealed today, following the release
of new statistics on major errors within the health service.
6
Overall there were 148 “never events” - medical mistakes that
according to guidelines should never happen - at NHS trusts
between April and September 2013. Foreign objects such as
needles, swabs and even a glove being left inside a patient
were the most common type of error - occurring 69 times.”
“Surgery was performed on the wrong part of the body 37
times, and at one hospital, a cardiac operation was performed
on thewrongpatient.One patient had thewrong toe removed,
and another received surgery on their left foot for a condition
affecting their right foot.”
6
The figure does not represent a major increase on previous
years. Between 2012 and 2013 there were 326 “never events,”
said Dr. Mike Durkin, NHS England’s national director for
patient safety, noting that investigations into the events were
on-going and it was not yet known how many had resulted
in death. “It is important to remember that all ‘never events’
should trigger a root causes analysis investigation and subse-
quent improvement in safety, even where the patients come
to minimal harm,” he said.
7
The following shouldbe the “Always” standardof practice to
avoidwrong site, wrongprocedure, andwrongpatient surgery:
1.The surgeon should review the actual diagnostic studies
performedby the referring physician to ensure he/she agrees
that the proposed procedure is indicated and appropriate
and that the level/lateral of the proposed procedure is
consistent with the study results.
2.The surgeon should ensure that radiologic reports are
carefully reviewed, appropriately documented and if hung,
then hung correctly.
3.The “Universal Protocols” for correct site, patient and pro-
cedure should be consistently complied with for all cases,
regardless of operating room turn-around times.
a. Every member of the surgical team speaking with the
patient pre-operatively should reaffirmapatient’s identity.
b. Every member of the surgical team speaking with the
patient should reaffirm the planned procedure and
location of the procedure (level, side, etc.).
c. The surgeon should consistently sign the surgical site.
4. In the event of surgical error or mishap, the surgeon as
“captain of the ship” should always take the lead in dis-
closing what occurred to the patient/family, in making a
sincere apology and in working with the patient/family in
resolving resulting issue according to major malpractice.
12
Any attempt to leave vital information out, cover up errors
or omissions will likely exacerbate the situation.
OB/GYN Complications
Studies conducted by the Centers for Disease Control
(CDC) and the American College of Obstetricians and Gy-
necologists (ACOG), conclude the leading causes ofmaternal/
pregnancy death are: hemorrhage, hypertensive disorder,
pulmonary embolism, amniotic fluid embolism, infection
and pre-existing chronic conditions.
8
One study that spanned
ten years indicated that the numbers of deaths related to
hemorrhage declined, while mortality attributable to other
conditions (e.g. cardiovascular, pulmonary and neurologic)
significantly increased.
It has become evident that heightened physician awareness,
coupledwith screening of pregnant womenwith pre-existing
condition/associated risk factors, will help preclude adverse
outcomes. Without comprehensive medical and social his-
tories, underlying factors may go unrecognized and result
in morbidity or mortality.
Hospital Corporation of America (HCA) examined indi-
vidual causes of maternal deaths among 1.5 million births
within124hospitals occurring between2002 and2007.HCA
