You wake up from surgery to find that the doctor operated on the wrong side of your body and took out your healthy ovary instead of the one with the mass. It happened to Nadege Neim, a young medical student. Neim’s attorney observed that “If it can happen to a medical student, it can happen to anyone.”
And it does. Mistakes like this happen about 40 times a week in the U.S.
Surgeries on the wrong side or site, or even the wrong surgery entirely, are known as WSPEs, which stands for wrong-site, wrong-procedure, wrong-patient errors.
The medical establishment calls WSPEs “never” events, meaning they should never happen. They are considered “avoidable,” but for some reason WSPEs are proving surprisingly difficult to prevent.
“The number of wrong site surgeries has gone up year after year after year, so we are becoming concerned about this,” says Dr. Dennis O’Leary, president of a hospital accreditation organization called the ”Joint Commission.”
ABC reports that “perhaps the most notorious case of wrong site surgery involved Willie King, who in 1995 went into a Tampa, Fla., hospital for surgery to amputate one foot badly afflicted by gangrene but had the wrong foot removed instead.” He wound up with no feet at all.
One woman with a cancerous lesion on the left side of her vulva had the right side removed instead. Someone else had a cardiac procedure that wasn’t even meant for that patient, but for another person with a similar name. The parade of horribles goes on and on.
A Solution? The Universal Protocol
The medical profession has tried putting an end to WSPEs. The Joint Commission implemented the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery in 2004, but it doesn’t seem to be helping — in fact, the problem may be getting worse, according to The Washington Post.
The “three principal components of the Universal Protocol include a preprocedure verification, site marking, and a time out.”
At Stanford Hospital the first component, the “pre-procedure verification,” includes verifying:
- “relevant documentation” like consent forms
- “labeled diagnostic tests” and any “required blood, implants, etc.,” verifying “the correct patient, correct procedure,” and correct site
- identifying all the items needed for the procedure and making sure they are available. The medical team should involve the patient in this process when possible.
The second component of the Universal Protocol, site marking, seems like a no-brainer: with a permanent marker, a member of the medical team indicates where the operation should take place. But it is not foolproof. In some cases there has been confusion about whether the markings indicated the side to operate on or the side not to operate on.
The Universal Protocol requires a third component, a time out before all procedures: “a planned pause before beginning the procedure in order to review important aspects of the procedure with all involved personnel.” Communications issues frequently play a role in WSPEs, and time outs are meant to prevent or resolve those issues.
The Agency for Healthcare Research and Quality, however, concludes that “many cases of WSPEs would still occur despite full adherence to the Universal Protocol. Errors may happen well before the patient reaches the operating room, a timeout may be rushed or otherwise ineffective, and production pressures may contribute to errors during the procedure itself.” “Production pressures” presumably means pressure on doctors to crank out as many procedures as possible, which is rather horrifying.
One study found that in 72 percent of cases, the Universal Protocol was not followed, and the researcher speculated that doctors resent the rule.
What Patients Can Do
Since the Universal Protocol has proven not to be a panacea for WSPEs, patients should take some measures themselves to try to prevent errors. The Joint Commission recommends that patients “discuss specifically what will be done…with both the surgeon and the anesthesiologist.” It advises that while they are still conscious, patients have the site of the surgery marked and have the surgeon initial it.
Pennsylvania’s Patient Safety Authority offers a fuller list of recommendations for patients:
- Don’t be upset if each doctor or nurse asks the same questions about your identity, procedure, and the side or site of the operation. They are supposed to individually check with the patient rather than accept what someone else has written or said.
- Make sure that you know which physician is in charge of your care.
- In addition to your name, give healthcare professionals another identifier, such as your birth date, to confirm who you are.
- If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done.
- Speak up if you have questions or concerns.
- If something does not seem right or if you do not understand something, say so. Ask for an explanation.
- Ask the doctor or nurse to mark the place that is to be operated upon.
- Make sure you have someone with you that you trust to be your advocate. This person can ask questions you may not think of and remember important information you may forget.
- Make sure all health professionals involved in your care know your medical history.
- Educate yourself about your procedure and don’t be afraid to get a second opinion.
Personally, next time I or a loved one needs surgery, I plan to stop every single employee I see and tell them exactly what needs to be done. I’ll talk to the billing administrator, the receptionist, whoever — better to be known as the Annoying Patient than miss a chance to prevent a disaster.