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Surgery on Wrong Patients, Surgical Sites Persists, Study Finds
Date:10/19/2010

By Steven Reinberg
HealthDay Reporter

MONDAY, Oct. 18 (HealthDay News) -- Patients undergoing surgery still risk falling victim to stunning medical mistakes, ranging from an operation on the wrong surgical site to undergoing surgery intended for another patient, a new study finds.

To try to curb the rate of surgical errors, the Joint Commission in 2004 introduced a universal protocol for all hospitals, ambulatory care facilities and office-based surgical facilities to follow. However, even though these steps have largely been adopted, errors continue to happen, the researchers reported.

"What is shocking about the data is that each and every one of those wrong-site, wrong-patient errors is really an event that should never happen," said study author Dr. Philip F. Stahel, a visiting associate professor at the University of Colorado School of Medicine in Denver.

"These happen much more frequently than we think. This is just the tip of the iceberg," he said. "Introducing the universal protocols have not reduced the frequency of these events."

The universal protocol requires three critical steps: a pre-procedure verification, marking the correct surgical site, and a "time-out" for the operating staff just before the surgery.

The report is published in the October issue of the Archives of Surgery.

For the study, Stahel's team collected data on surgical errors from a company that provides liability insurance to 6,000 doctors in Colorado.

In the database, doctors reported 27,370 adverse events that happened between January 2002 and June 2008. Among these, the researchers identified 25 wrong-patient and 107 wrong-site operations.

Of these, five patients who received unnecessary surgery and 38 who received wrong-site operations were significantly harmed, the researchers found. In addition, one patient who had a wrong-site procedure died.

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