Wrong Site Surgery — What Happens Next?

I don’t usually write about local or state news because my work is really more broad than that — however — an article in my local newspaper about a local hospital and wrong-site surgery just begged for some additional information!

Wrong site surgery — a “never event” that takes place an estimated 100 – 200 times per year in the United States. In this case, the patient was supposed to have his fractured right hip replaced with a new one. However — the patient woke up in the recovery room with — surprise! — a new LEFT hip. Yes, the surgeon had replaced the wrong hip. And of course, the right hip was still in the same fractured state it began with.

I can only imagine that this mistake took place like most of the wrong-site surgical mistakes do. In a hurry (because, never forget – time equals cost), shortcuts were taken. And who pays the price? The patient, of course. Oh yes, the hospital will now pay a $ 6,000 fine, too — more about that in a moment.

According to the article and the New York State Health Department, this is what took place:

  • Instead of marking the skin on the correct hip with a skin marker, the surgeon used a ball-point pen.
  • + The surgical nurse didn’t know whether or not the skin had been marked, so he or she prepped the wrong hip.
  • + The nurse who transported the patient to the operating room never verified the correct side either.
  • + The “time out” process, which is required by the Joint Commission (the group that accredits hospitals) was not followed. (Of course not — time OUT is expensive!) There are actually three required Time Outs: 1 – before anesthesia, 2 – before any cuts are made, and 3 – post surgery, they are expected to account for all the tools and materials used that should not be left behind in the patient.
  • + The MRI films were not displayed in the OR for review prior to the surgery.

= one patient who is far worse off than when he or she was admitted to the hospital for surgery.

There’s no mention of what happens to the medical personnel who made the errors. One can only hope they are being dealt with. (And I won’t even go into the hospital policies that caused them to take short cuts to begin with. Were they running behind? Were they pressured to make up time? No excuses — but I do recognize that the pressures on these folks are outrageous, and then, as usual, we patients pay the price….) But I digress…

The hospital was fined $6000. I wondered — who gets that fine money? Where does it go? Hospitals all over New York State (and every other state, too) get fined on a regular basis. Does the money simply enhance the general budget? (Are we going to try to make up for Wall Street’s woes by fining healthcare facilities?)

So I called the New York State Health Department. After several minutes of being passed around from one department to another — I actually found someone who was very helpful! Peter Farr, from the Bureau of Hospitals, explained that until recently all that money simply got deposited into the general fund. BUT! Recent new legislation has established the Patient Safety Center, and now most of the fine money will be funding that program. The Patient Safety Center will be tasked with transparency issues — reporting all that data that we patients have not had access to, but will begin seeing (and hopefully using) in the near future.

You know, though, we patients can all learn from this wrong site surgery story:

  • If you will have surgery, mark the area of your body that is to be operated on. Use a marker that won’t wash or rub off right away (like a sharpie), and mark “THIS HIP” or “CUT HERE!” or whatever works for the surgery you’re about to have.
  • Then mark the area that could be mistakenly opened. “WRONG HIP” or “NO! NOT HERE!” on parts that could be cut accidentally.
  • Before they give you that pre-sleep drug, and anytime you see or encounter anyone who might be in the OR, remind them to take their “Time Outs.” Don’t worry about whether someone will be in the OR or not — assume they all will, and remind them all. Ask your loved one or advocate who is with you before your surgery to do the same.

I have to think that the surgical personnel at this hospital are just as appalled as anyone else about this mistake. They will be second-guessing themselves for a very long time, and I’m sure they will be correcting themselves and being far more careful in the future.

So my advice is simply for the rest of us to learn from their errors — and perhaps to think some good thoughts for that poor patient who had two hips replaced in one day, and will hopefully recover 100 percent.

(PS — If you are the patient, why not get in touch? We’ll keep your identity anonymous, but we’d love to hear your impressions…. email blog (at) epadvocate.com. )

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