How Hospitals Can Avoid Surgical Mistakes
Friday, March 1, 2013
Aired 3/4/13 on KPBS Midday Edition.
Dr. Martin Makary, Author of New York Times best selling book Unaccountable
Dr. Geoffrey Stiles, Chief Medical Officer at Sharp Memorial Hospital
Whenever there are dramatic surgical mistakes, we usually hear about it. For instance, we hear of a patient who had the wrong leg removed or, as happened at a Kaiser facility here in San Diego a surgery which removed a healthy kidney, and left the kidney with the cancerous tumor in tact. But there are hundreds more cases of less dramatic surgical errors, including objects left inside patients.
The medical profession refers to all these mistakes as "never events", in that they should never happen.
A new study of surgical errors in the US has just been published online in the journal Surgery. It was lead by Dr. Martin Makary, associate professor of surgery at Johns Hopkins University.
According to the study, Dr. Makary and the other researchers identified 9,744 malpractice payments tied to surgical 'never events' between September 1990 and September 2010. About 50% of the cases involved a foreign object left behind and the other half were either categorized as wrong procedure or wrong site.
"These cases are 100 percent preventable" Dr. Makary said.
But the American Hospital Association says the study covers years before many prevention efforts were put in place.
Still, Dr. Makary says we've got an endemic of mistakes.
"Surgery is safe, these are extreme cases, but medical mistakes are the number three cause of death in the United States."
In addition to the cost of pain and suffering to patients, surgical mistakes are costly to US hospitals. In 2012, five local hospitals got hit with fines for placing the health and safety of patients in immediate jeopardy.
Across California, hospitals are stepping up their efforts to curb medical errors. In San Diego County, Sharp HealthCare implemented stringent guidelines aimed at reducing the number of wrong-site surgeries. That's when a surgery is performed on the wrong side or site of the body. It also includes surgery performed on the wrong patient.
"It's an extremely rare occurrence" said Dr. Geoffrey Stiles, Chief Medical Officer at Sharp Memorial.
He says Sharp Memorial fully implemented the new rules November 1, 2012. The hospital performs more than 20,000 surgeries each year.
The rules include going through a checklist, much like the airline industry and having x-ray's in the operating room before a surgery.
Dr. Stiles says not a single wrong-site surgery has been performed at Sharp Memorial since the program's implementation. But he warns it's still too early to tell if the new guidelines are successful since wrong-site surgical mistakes happened at a rate of one per 18,000 surgeries at that hospital.
One thing Dr. Makary says could revolutionize health care is transparency.
"I believe the public has have a right to know about the quality of their hospitals. You have more information about the restaurants you go to than the hospitals you go to," he said.
The California Department of Public Health collects data on "never events" for individual hospitals but it does not make that information accessible to the public on its website. Instead, the agency offers statewide data that shows there were 340 surgical mistakes performed during the 2011-2012 fiscal year at California hospitals.
California Surgical Mistakes
Surgical Mistakes California Department of Public Health
KPBS has highlighted what other hospitals are doing to cut back on medical mistakes. At Palomar Medical Center in Escondido, efforts are underway to make sure patients aren't given the wrong medication.
Recently, KPBS Health Reporter Kenny Goldberg also featured a local company that is offering a solution to the most common surgical mistake: leaving sponges inside patients.