Major Surgical Errors Persist Despite Safety Protocols


November 17, 2012

Despite clear protocols designed to reduce the risk of major surgical errors such as wrong site surgery and similar egregious mistakes, these errors still occur, including:

  • Conducting the wrong surgical procedure
  • Performing surgery on the wrong patient
  • Surgery on the wrong side of the body or wrong limb

While it may seem mind-boggling that such blatant errors occur, they are far more common than the typical surgical patient would suspect. These types of egregious surgical errors still occur at an estimated rate of approximately forty per week. There is a prescribed set of procedures that were developed by the Joint Commission, a group that certifies health care providers as far back as 2004. The protocols developed include:

  • Identification of the surgical site by marking it
  • Verifying the appropriate surgical procedure
  • Taking a time out prior to the surgery

These protocols were supposed to be mandatory in hospitals, but many surgical teams fail to comply with these protocols. The irony is that these protocols were considered so simple and commonsense that it was presumed that adopting procedures like marking the surgical site and conducting a timeout could help stop doctors from amputating the wrong leg, cutting into the wrong patient, or performing the wrong surgery.

Unfortunately, many surgical teams lack communication and a cooperative atmosphere that seriously compromises the effectiveness of these protocols. The Joint Commission has found that the frequency of wrong site surgery or amputation of the wrong limb is far less likely if the surgeon communicates with the patient in the pre-operative area rather than seeing the patient for the first time in the operating room.

Cooperation and communication with the surgical team is also critical. Many times the attitude of the head of the surgical team can have a significant impact on the likelihood of this type of surgical error. Recent studies have shown that introductions in the operating room and efforts by the leader of the surgical team to encourage other members of the team to say something if they see a potential problem can greatly reduce the risk of surgical mistakes. Atul Gawande, a Harvard Medical School surgeon, found that introductions in the operating room reduced the risk of surgical complications by as much as 35 percent.

If other members of the surgical team are afraid to alert the head of the surgical team of potential issues, it substantially increases the risk of making gross surgical errors. Without introductions and a clear indication that cooperation is welcome, some members of the team are afraid to suffer the wrath of the head of the surgical team. A recent example involves a technician on a surgical team that recognized that the surgeon was going to operate on the wrong side but did not say anything until after the procedure because he was afraid of angering the surgeon.

A timeout prior to the surgical procedure is also very effective but frequently ignored. Timeouts allow the entire surgical team to verify the correct person, procedure, and site. A recent study of wrong site errors in Colorado found that in 72 percent of 132 cases the surgeon did not take a timeout prior to the surgical procedure.

If you or someone you love has been seriously injured or suffered wrongful death, you or your loved one may be entitled to financial compensation. Contact us for a free consultation with an experienced Atlanta medical malpractice attorney. At Montlick and Associates, Attorneys at Law, we have been helping Georgia families get the compensation they deserve since 1984. We are available to assist clients throughout all of Georgia including, but not limited to, Albany, Athens, Atlanta, Augusta, Columbus, Dalton, Gainesville, Macon, Marietta, Rome, Roswell, Savannah, Smyrna, Valdosta, Warner Robins and all smaller and rural towns in the state. Call us today for your free consultation at 1-800-LAW-NEED (1-800-529-6333), or visit us on the web and use our 24/7 Free Live Online Chat at www.montlick.com. No matter where you are, we are just a phone call away and we will even come to you.

Category: Personal Injury

Please Note:
Many of our blog articles discuss the law. All information provided about the law is very general in nature and should not be relied upon as legal advice. Every situation is different, and should be analyzed by a lawyer who can provide individualized advice based on the facts involved in your unique situation, and a consideration of all of the nuances of the statutes and case law that apply at the time.