September 19, 2008 | Mark Paradies

Amazing that Surgical Errors Like This Still Occur

A wrong site surgery is a 100% preventable event. The administrative controls are fairly simple to implement. Yet, we still have wrong site surgeries.

An article from the Central New York News details an wrong site surgery on a patient’s hip. It seems that:

• The surgeon used a ballpoint pen, instead of using an FDA-approved skin marker, to initial the incision site on the correct side of the patient.

• The nurse who prepared the patient’s wrong hip for surgery did not see the site marking. The nurse ” … does the prep so automatically, he/she is not sure if he/she always looks for the markings.”

• Another nurse transported the patient to the operating room without checking to verify the correct side.

• Members of the surgical team did not follow verbal and visual verification procedures to make sure the patient was positioned correctly for surgery.

• MRI pictures relevant to the procedure were not displayed in the operating room before surgery began.

The hospital was fined $6,000 by the New York Health Department. They also had to perform the surgery again (not clear if they were paid twice for the surgery).

As part of the settlement, the hospital – St. Joseph’s Hospital Health Center in Syracuse, NY, agreed to take corrective action to prevent surgical mistakes.

My question is … Why didn’t they do this a decade ago?

Reading current stories like this one makes me shake my head in disbelief. Why isn’t the whole healthcare industry far beyond this point in advanced methods to assure error free human performance that are used in high reliability industries (for example, aviation and nuclear). Why aren’t more hospitals attending the TapRooT® Summit to learn best practices from other high reliability industries?

It seems that investing in malpractice insurance is the first approach to reducing risk rather than eliminating the real root causes of the lawsuits that result after one of these needless sentinel events.

If your hospital is ready to start effective learning from sentinel events, then it is time to go beyond basic root cause analysis tools and learn advanced root cause analysis at a TapRooT® Root Cause Analysis Course. For more information, see:

http://www.taproot.com/courses.php

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