St. Joseph doctors fix wrong knee
St. Joseph Hospital in Orange is under state investigation for mistakenly doing knee-repair surgery on a patient’s good knee, the third “wrong-site” procedure to occur at Orange County’s largest hospital since January 2006.
The Feb. 15 operation was intended to repair a patient’s left knee but was “inadvertently performed on the right knee,” according to a statement released by the hospital in response to questions from The Times. Citing privacy concerns, the hospital declined to identify the patient or release other details.
The other incidents involved an incision made on the wrong side of a patient’s head, which occurred in January 2006 and was “promptly corrected,” and an ear tube inserted in the wrong ear last June, according to Sonoma Van Brunt, the hospital’s vice president for marketing, public affairs and business. There were no further complications from the errors, she said.
“No patient should ever have to go through an experience like this,” Dr. Raymond Casciari, St. Joseph’s chief medical officer, said in an e-mailed statement. “There is no room for error when it comes to patient care. One case is one too many.”
The California Department of Public Health investigation marks the second time in recent months that a well-known Southern California hospital has come under public scrutiny for medical mistakes. State investigators found that three children, including the twin children of actor Dennis Quaid, received 1,000 times the intended dose of the blood thinner heparin in November while being treated at Cedars-Sinai, one of the nation’s most prestigious hospitals.
“I’ve got to believe that St. Joseph’s is beside itself trying to figure out what’s not working,” said Jim Lott, executive vice president of the Hospital Assn. of Southern California.
The investigations of Cedars-Sinai and St. Joseph underscore the difficulty hospitals have had preventing medical mistakes almost a decade after the Institute of Medicine shocked the nation by reporting that an estimated 100,000 people died each year in the U.S. from hospital errors. Later studies would call the 1999 estimate -- about the same as the yearly tally from motor vehicle accidents, breast cancer and AIDS combined -- too low.
“That report was kind of the epiphany moment,” said Dr. Peter Angood, vice president and chief patient safety officer for the Joint Commission, a national organization that accredits hospitals. “But we have not achieved truly significant improvements in patient safety or the prevention of these adverse events.”
The slow progress is particularly disappointing in light of the increased awareness of errors and the promotion of specific steps to prevent them, Angood said.
The Joint Commission, for example, developed a protocol for preventing wrong-site surgeries, a category that includes operating on or removing the wrong limb or organ, doing the wrong procedure or treating the wrong patient.
Doctors are supposed to mark the spot they plan to cut in consultation with their patients before surgery. Nurses are supposed to call a “time out” in the operating room for a final check.
The approach acknowledges that humans make mistakes, so checks must be built into the system at various steps to catch them.
Safety experts agree that the protocol works -- when used. But a multitude of factors can interfere with its use, ranging from simple distractions found in any busy operating room to an entrenched culture in which some surgeons resent having to follow step-by-step instructions and some nurses are afraid to speak up.
The monitoring of protocols is also a factor, which St. Joseph Hospital learned in 1999 after a Tustin couple left the hospital with a baby who did not belong to them. The switch happened despite procedures put in place after three earlier mix-ups, including a mother breast-feeding the wrong infant. The hospital acknowledged that no one had checked to see whether nurses were following the new rules. It immediately announced an overhaul of maternity ward policies.
St. Joseph had adopted the Joint Commission’s recommended protocol on wrong-site surgeries, Van Brunt wrote in an e-mail. She declined to give details about whether the internal investigations launched after each of the three incidents found common flaws. According to Casciari, the hospital has reinstituted a “top-to-bottom training program.”
“Members of the clinical team involved in these cases have been deeply affected, and as a hospital we take this very seriously and regret that it happened,” Casciari said.
Wrong-site surgeries are considered rare in the context of the number of surgeries performed each year. St. Joseph, for example, does about 25,000 surgeries a year, according to Van Brunt.
But just how rare they are is difficult to pinpoint.
About eight wrong-site surgeries are reported each month to the Joint Commission’s voluntary reporting system, but they represent only the most serious cases, with 70% of them resulting in death.
Just over half the states have some sort of mandatory reporting system. Since July 1, California has required the reporting of more than 20 serious medical errors listed by the National Quality Forum, a group of consumers, doctors, insurers and institutions promoting improved quality in healthcare.
The first report, from July through November, listed 22 “wrong-site” events statewide, including 14 incidents of surgery performed on the wrong body part, one case of surgery performed on the wrong patient and seven cases of the wrong surgical procedure performed on a patient. The most frequently reported errors involve bed sores acquired after admission (125 incidents) and objects such as scissors, scalpels or sponges left in patients (59).
Hospitals soon will encounter even more pressure to prevent errors.
After Oct. 1, Medicare will no longer pay for follow-up care for several preventable problems.
Health insurer Aetna is requiring hospitals to waive patient bills when certain medical errors occur and to apologize to families of the patients hurt by the mistakes, the company said.
“From the patient’s perspective, people want to know why did it happen and they want someone to say that they’re sorry,” said Fran Griffin, project director at the nonprofit Institute for Healthcare Improvement in Cambridge, Mass. “And they’re very appreciative if there’s some follow-up to say, ‘This is what we’re doing to make sure it doesn’t happen again.’ ”