By Sandra Boodman
When the president of the Joint Commission, the Chicago-based group that accredits the nation's hospitals, unveiled mandatory rules to prevent operations on the wrong patient or body part, he did not mince words.
"This is not quite 'Dick and Jane,' but it's pretty close," surgeon Dennis O'Leary declared in a 2004 interview about the "universal protocol" to prevent wrong-site surgery. These rules require preoperative verification of important details, marking of the surgical site and a timeout to confirm everything just before the procedure starts.
Mistakes such as amputating the wrong leg, performing the wrong operation or removing a kidney from the wrong patient can often be prevented by what O'Leary called "very simple stuff": ensuring that an X-ray isn't flipped and that the right patient is on the table, for example. Such errors are considered so egregious and avoidable that they are classified as "never events," because they should never happen.
But seven years later, some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse, although spotty reporting makes conclusions difficult. Based on state data, Joint Commission officials estimate that wrong-site surgery occurs 40 times a week in U.S. hospitals and clinics. Last year 93 cases were reported to the accrediting organization, compared with 49 in 2004. Reporting to the commission is voluntary and confidential -- to encourage doctors and hospitals to come forward and to make improvements, officials say. About half the states, including Virginia, do not require reporting. In two states that track and intensively study these errors, 48 cases were reported in Minnesota last year, up from 44 in 2009; Pennsylvania has averaged about 64 cases for the past few years.
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