Wrong-Patient and Wrong-Site Procedures Persist in U.S. Healthcare System

Thursday October 8, 2020

A recent study conducted by a team of medical doctors in Colorado found that wrong-site and wrong-patient surgery mistakes, considered “never events” by the National Quality Forum, are being made at rates surpassing those found by previous studies, despite known ways to prevent such mistakes from occurring.

The research team compiled a database of 27,370 physicians who self-reported mistakes. In these reports, there were 25 instances of surgery performed on the wrong patient – five of which led to significant harm to the patient. One hundred and seven incidents in which surgery was performed on the incorrect site were reported, and 38 of these resulted in significant harm to patient, and in one instance, death.

Several factors contributed to these high numbers. In all of the wrong-patient mistakes, errors in communication were cited as one of the causes, and over half of the mistakes were also the result of misdiagnosis. Errors in judgment were to blame for 85 percent of the wrong-site mistakes. In both cases, failure to take a “time out” to verify the surgery plan contributed to mistakes 72 percent of the time.

Progress against wrong-patient and wrong-site procedures is being made in the Veterans Affairs hospital system. A recent study of the VA system, published in the October 2010 edition of the Journal of the American Medical Association, revealed that when VA medical teams worked together to prevent mistakes, the rate of wrong-patient and wrong-site errors decreased significantly.

The VA medical teams used a variety of strategies to combat these surgical errors. In some cases, the team for a particular patient worked together to form a surgery checklist and perform pre-surgery briefings. When these tactics were implemented over three years at 74 different VA hospitals, fatal surgery errors fell by 18 percent.

Since 2003, the VA has made sure that surgical teams, not just head surgeons, are responsible for the surgery checklist and briefings before, during, and after each surgery. Surgical teams now double-check with a patient prior to sedation about which surgery they have been told will occur and read off the surgery checklist to patients.

The decrease in wrong-patient and wrong-site procedures at VA hospitals is encouraging, but unless the VA’s surgical strategies are adopted nationwide, chances of decreasing similar wrong-patient and wrong-site mistakes at other hospitals are slim.

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