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Taking Precautions Against Medical Mistakes : Health: Hospitals have procedures to prevent accidents in the operating room. But there are steps patients can take to further minimize the risks.

SPECIAL TO THE TIMES

Just before Sylvia Ann Gallegos was due to undergo knee replacement surgery last month at Orthopaedic Hospital in Los Angeles, the 38-year-old rheumatoid arthritis patient grabbed a pen and scribbled some last-minute instructions in a place that couldn’t be missed.

She wrote “No” on her right knee and “Yes” on her left.

At first, she says, she did it “just to be silly.” But the more she thought about it, the better it sounded.

Like other Americans, Gallegos had heard about the recent surgical mistakes at a Florida hospital, one involving amputation of a wrong foot. So, while Gallegos says she had confidence in her surgeon, she wanted to minimize the risk of mistakes in any way possible.

Her 11th-hour ritual is hardly outlandish, as growing numbers of patients worry about operating room mix-ups, their anxiety fueled by half a dozen surgical or medical mistakes that have come to light recently:

* At University Community Hospital, a 424-bed facility in Tampa, Fla., three other mistakes besides the wrong-foot operation have been reported since Feb. 15. A respirator was mistakenly turned off and the patient died, an arthroscopic procedure was performed on the wrong knee, and a woman’s Fallopian tube was tied by mistake after a Cesarean delivery.

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* At the prestigious Dana-Farber Cancer Institute in Boston, two women received chemotherapy overdoses. One died in December, the other remains hospitalized.

In the wake of these publicized incidents, patients naturally wonder what their risks are during hospitalization and surgery, what policies are in place to reduce the odds of mistakes, and if there’s anything short of scribbling on body parts they can do.

The chances of medical and surgical mistakes--termed “misadventures” by statisticians--are relatively slim in the United States, according to the National Safety Council.

In 1991--the most recent year for which figures are available--"misadventures” left 2,473 people dead, according to the 1994 edition of “Accident Facts” published by the council. More than 31 million persons were discharged that year from U.S. hospitals. This does not include federal hospitals or newborns. (In California, 74 deaths were attributed to medical or surgical misadventures in 1993, says Scott Lewis, a spokesman for the California Department of Health Services, compared to 63 in 1991 and 79 in 1992.)

By comparison, in 1991, 75 people died after being struck by lightning in the United States, and 43,536 deaths resulted from motor vehicle accidents.

“The risks are quite low,” says Dr. Leon Cohen, assistant medical director at Kaiser Permanente Medical Center in Panorama City.

To reduce the likelihood of such mix-ups, hospitals use detailed guidelines from the Joint Commission on Accreditation of Healthcare Organizations, a private nonprofit group that evaluates and accredits more than 11,000 health-care facilities, including 80% of the nation’s hospitals. Typically, hospital personnel then work with their risk managers to fine-tune the policy.

While the commission guidelines do not specifically address, for example, the measures to be taken to ensure a correct limb is operated on, guidelines state that the medical record should be reviewed with the patient before surgery, and that that information should include the limb to be operated on, says Suzanne Gylfe, a spokeswoman for the commission.

Failure to adhere to the guidelines could result in loss of accreditation and jeopardize state licensure and Medicare funding, Gylfe says.

In a random survey of nine hospitals contacted for this story, officials said they believe their policies are adequate, and some said they plan to re-evaluate their policies in the wake of the Massachusetts and Florida mishaps.

(The hospitals polled were Cedars-Sinai Medical Center, Childrens Hospital Los Angeles, St. Joseph Medical Center, Kaiser Permanente, Martin Luther King Jr./Drew Medical Center, Orthopaedic Hospital, Santa Monica Hospital Medical Center, New York Hospital-Cornell Medical Center in New York, and Rush-Presbyterian-St. Luke’s Medical Center in Chicago.)

While policy may vary slightly from hospital to hospital, each relies on a system of checks and balances and double-checking by medical staff. The policy in force at Orthopaedic Hospital, for instance, involves many steps, says Dr. James V. Luck Jr., president and medical director.

“The patient comes in two days before surgery to the hospital and sees the nurses on the surgery floor,” Luck explains. “They go over which side (in the case of limb surgery) and the consent (form) with the patient. The patient is then brought into the hospital on the morning of surgery and the nurse on the floor checks it again. That is the nurse who will let the patients write on the leg (or other limb) if they’re nervous.

“When the patient gets to the (operating room), the O.R. nurse checks it again.

“The fourth check is (done by) the anesthesiologist. The fifth check is the surgeon.”

In some cases, he adds, the surgical residents and the surgeon will recheck. “So there are five or six levels of checking,” Luck says.

“Each step reduces the probability of a mistake,” Luck says. “If five or six people are involved, the risk reduces to close to zero.”

Officials at other hospitals describe similar systems of checks and balances, with checking and rechecking of the consent form with the medical chart and the patient. Most hospital officials say they rely on interaction between staff and patients to ensure safety.

At Santa Monica Hospital Medical Center, for instance, patients identify themselves and the reason they are there several times before surgery, says Keith Bradkowski, a nurse who serves as administrative director of patient care services.

“If something is to be removed or amputated, they point to it, what side it is on,” he says. “It’s important (for patients) to realize we are going to ask those questions. We don’t want the patient to think we don’t know what’s going on.”

Typically, the same double-check system is also in place at hospital pharmacies.

“We screen every order for appropriate dose, drug interactions, drug-food interactions,” says Amy Gutierrez-Pickett, director of pharmacy services at King/Drew Medical Center. “We contact the physician if there are any questions.”

Pharmacists dispense what is needed for a 24-hour period, Gutierrez-Pickett says, and this medicine is kept in individual, labeled cassettes for each patient.

Before giving medicines, a nurse checks the medicine in the cassette against the medication administration record kept on the nursing unit. Nationwide, these records and other data are randomly inspected when a team from the Joint Commission on Accreditation of Healthcare Organizations surveys hospitals every three years to review accreditation status. In California, the commission surveyors are joined by representatives from the California Department of Health Services and the California Medical Assn.

“We’re the only state in which the medical association participates,” says Sydney Reed of the CMA, explaining that the arrangement results in a more intensive review.

At University Community Hospital in Tampa, officials have instituted new policies in the wake of the mishaps, says spokesman John Andreas. The hospital was required by the federal Health Care Financing Administration--which threatened to pull up to $50 million in government health insurance payments for Medicare--to file a corrective action plan by last Monday.

While much of the plan is confidential, two new policies have been discussed publicly, Andreas says. One new procedure requires marking “No” on a limb not to be operated on; the other requires more staff interaction. “The physician and operating room nurse will (now) confirm the operation and the site with a third person who will be reading the information off the signed surgical consent form,” Andreas says.

At Dana-Farber, “there have been modifications of the computer software in the pharmacy,” says spokeswoman Gina Vild. Under the existing method, there were several double-checks in place to ensure that a chemotherapy dose was the correct one for an individual patient, she says. Under a new system, the maximum dose of high-dose chemotherapeutic agents is keyed in to the computer according to the body weight of an individual patient, she says, thus providing yet another safeguard.

And what can patients do to minimize mistakes? The hospital is no place to be timid. Patients should take an active role to further reduce the risk of error.

They should communicate fears and concerns, carefully read all hospital forms (including the fine print) and ask questions.

“Be sure the consent form has details about the procedure,” advises Jan Decker, a registered nurse and the nurse-manager for operating room services at Cedars-Sinai. It’s not enough, for instance, to list “biopsy”; instead, list “biopsy, left breast.”

Interpreters are often available on-site for non-English speaking patients. If needed, hospitals can tap in to the telephone company’s interpreter line. Hearing-impaired patients can ask the hospital to provide signers.

When heading for the hospital, perhaps it’s best to be both optimistic and realistic. Says Candis Cohen, spokeswoman for the Medical Board of California: “If I were having, say my left arm removed, I would write in black felt tip pen on my right arm: ‘Not this arm.’ I don’t mean to insult physicians. Nonetheless, if it were me, I’d get out that black felt pen.”


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