New Alert Issued on Surgery Errors

A hospital regulatory agency is warning of an alarming increase in incidents in which doctors operated on the wrong body part or the wrong patient.

Wednesday’s alert from the Joint Commission on Accreditation of Healthcare Organizations follows a similar message from the group in 1998, when it reported on 15 “wrong-site” cases.

Since then, 136 cases have been reported to the commission--108 in the last two years and 11 in the last month alone.

“This is really an embarrassment for any place that has this happen. This is not infrequent,” said Dr. Dennis O’Leary, commission president.

Such errors are preventable with measures as simple as using a marker to scrawl messages like “Operate Here” on the patient’s body, he said.

Most cases involve orthopedic or foot-related surgery--operating on the left knee instead of the right knee, for example.

Of 126 cases analyzed by the group, 76% involved operating on the wrong body part, 13% involved surgery on the wrong patient and 11% involved the wrong surgical procedure.

“You get patients with similar names, X-rays get reversed in view boxes, people are too busy or rushed to check charts and sooner or later something happens,” O’Leary said.

In a joint effort with the American College of Surgeons and the American Medical Assn., the commission is stepping up surveillance of such errors.

The commission plans to start close monitoring of hospitals early next year, and those that are not in compliance with patient-safety procedures could risk losing their accreditation, O’Leary said.

Most cases involve a breakdown in communication between the surgical team and the patient and his family.

The commission said surgical teams should consider taking a “time-out” in the operating room to make sure they have the correct patient, procedure and surgery site.