Communication failures such as poor handoff of critical information between
surgical team members are the leading cause of surgeries involving the
wrong patient, the wrong side, the wrong body part, the wrong implant or
the wrong procedure.
Poor communication was the cause of one in five adverse events reported to
the Veterans Health Administration system from 2001 to 2006, according to a
study published in November's Archives of Surgery
(archsurg.ama-assn.org/cgi/content/abstract/144/11/1028/). Problems during
the perioperative timeout process were a root cause of errors more than 15%
of the time.
The mistakes appeared to be rare, occurring once every 18,955 surgeries,
although a definitive wrong surgery rate could not be established, because
some errors go unreported, the study found. A total of 209 adverse events
were reported, as were 314 "close calls" in which mistakes were caught
before patients were harmed. Of the adverse events, 12% were serious enough
to merit root cause analyses.
The VA system in January 2003 adopted a directive for preventing wrong
surgeries. The Joint Commission's similar protocol took effect in June
2004. The safety procedures require surgeons and other health professionals
to implement a redundant system of checks of the patient's identity, test
results, the procedure to be performed and the surgical site. A pre-op
timeout for one last check also should be performed.
When those steps are followed, wrong surgeries do not happen, said study
co-author James P. Bagian, MD. "We didn't have any adverse events reported
where people followed the procedures," said Dr. Bagian, director of the
VA's National Center for Patient Safety since 1998.
About half the mistakes occurred in operating rooms, while the other half
involved minor surgical procedures performed outside the OR. Studies have
estimated that between five and 10 wrong surgeries occur every day in the
U.S.
According to the VA study, communication mistakes can become entrenched and
overlooked at the timeout stage. "The team may have already fixed in their
mind the surgical procedure to be performed."
Dr. Bagian said better adherence to safety protocols is the key to
preventing these surgical errors. "The thing that chagrins me is we have
[adverse events], and people didn't follow the procedures. It doesn't take
any longer to do these things. Instead of chit-chatting about the football
game, you ask who the patient is and what the procedure is that you're
doing."
The full and original article can be found here:
http://www.ama-assn.org/amednews/2009/12/07/prsf1211.htm
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