I read my medical journals in bulk. This means that I let them stack up for a while and read the whole pile, rather than reading them as they come in. The whole act of reading medical journals is rather antiquated in fact, as the world’s knowledge is at everyone’s fingertip and I really should spend the time practicing how to retrieve information faster rather than reading journals while watching LSU lose at football.

That thought aside, I read a New England Journal article from earlier this month written about a wrong site surgery (the lay press version can be found here). Wrong site surgery is a type of medical error known as a “never event.” These are errors that are considered so egregious that the physicians who are involved have become targeted for public labelling as have the hospitals. This event became newsworthy because the surgeon requested the public airing of the case, the hospital was the Massachusetts General (considered one of the best in the country). I also suspect it was allowed to be published because, although embarrassing, it was a procedure on the patients wrist that did not result in a loss of life or limb to the patient. The surgeon and the discussant identify a loss of concentration due to distraction from usual routine, a deviation from rule based behavior, and a language barrier complication as causative contributors to the error

This surgery happened in 2008. In 2002 the Joint Commission, the main accreditation body for hospitals, issued a set of guidelines for hospitals and physicians specifically designed to prevent wrong site surgery. These included processes for the team to verify that the right patient is about to have the correct surgery. This process includes stopping before the surgery with everyone having to agree on what is about to happen before further progress can be made. Despite the re-issuance of enhanced universal precaution rules in 2010 found here, approximately 180 wrong site surgeries are reported annually. The Mass General has reported the following changes as a result of this case

The universal protocol stipulates that the patient, when possible, should participate in the verification process by reviewing the consent form, identifying himself or herself as the patient, and identifying the procedure. After that, the surgeon marks the surgical site, with input from the patient if possible; site marking is no longer the nurses’ responsibility. The use of alcohol-based preparations that may erase the marking ink has been discontinued. The time-out is to occur once the patient is in the final position, prepped and draped, just before the incision is made. During the time-out, the patient’s identity, the site, and the procedure are again verified. The surgical scrub nurses are instructed not to hand the knife to the surgeon until the time-out is finished. There was an intensive educational program at this hospital for surgeons and nurses when these policies were rolled out.

The funny thing is that all of these steps were suggested by the Joint Commission in 2003 and I suspect the hospital’s policies dictated these actions before every surgery at the time of the incident.

As an added protection to protect patients from hospitals the Joint Commission has helpfully put together a patient instruction sheet to help patients partner with their physicians to prevent wrong site surgery.

This contrasts with the reaction that of the Captain of JetBlue Airways Flight 292. He had to an indicator light that revealed a suspected problem and, through following protocols, he was able to bring down the plane safely with no injuries. The entire team followed established procedures (all caught on film) I’ll bet no passenger had to remind the pilot and crew to be careful before take-off. More importantly, even though no one was injured, an investigation identified the likely cause of the problem and suggested how to fix it. I hope that we will one day practice in an environment that on the rare occasion that someone came close to having an error occur an investigation would lead to improvement without actual harm being done. For that to happen physicians, like pilots, will have to embrace protocols. The environment will have to be one where all involved can feel safe when pointing out potential problems.

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