Upcoming procedure? Interesting reading

Subject: Upcoming procedure? Interesting reading Tue 19 Oct 2010, 11:00 am

I know this has nothing to do with addiction, recovery or substance abuse. But this section is for everyday topics. Just because we are a recovery forum doesn't meant that we cannot talk about others things.
I do a lot of reading online and this morning this bit of news caught my eye and I wanted to share it with all of you.
Comments are welcome, as always.

Upcoming procedure? Interesting reading Earth_11

Published October 18,2010
Wrong-site, wrong-patient procedures are happening more often than suspected despite national quality improvement efforts, and surgeons aren't the only ones to blame, researchers found.

Over a six-and-half-year period, Colorado physicians reported 25 wrong-patient and 107 wrong-site procedures to a liability insurance database, Philip F. Stahel, MD, of the Denver Health Medical Center and University of Colorado Denver, and colleagues found.

"These data reveal a persisting high frequency of surgical 'never events,'" they wrote in the October issue of the Archives of Surgery, adding that "these numbers are considerably higher than previously reported in the peer-reviewed literature."

The Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol -- specifying preprocedure verification, surgical marking, and a "time out" before starting surgery -- has been in effect since 2004 but only helps when followed, they noted.

Failure to heed one of the components of the safety protocol was implicated in a large proportion of the cases in the study, which included not only actual completed surgeries but also those recognized before the first cut and even procedures such as vaccinations and radiation therapy.

Nonsurgical specialists were just as likely to cause significant injury from wrong-site errors as those in the procedural specialties, who have gotten more of the focus (31.2% versus 30.8%, P=0.67).

That's because, in their analysis, the researchers put the responsibility for wrong procedures at the step where things went wrong, Stahel told MedPage Today. And sometimes that's before the cutting stage.

"In certain cases we realize that the harm is already done before the patient sets foot in the hospital," he told MedPage Today.

"Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to achieve a zero-tolerance philosophy for these preventable incidents," Stahel's group wrote.

The real magnitude of the problem is still higher than Stahel's study indicated, wrote Martin A. Makary, MD, MPH, of Johns Hopkins, in an invited commentary accompanying the paper.

The self-reported incidents were not anonymous, so reporting bias was likely magnified by the stigma of such events, Makary noted.

"We should also avoid the trap of concluding that these are rates of events when in fact they are rates of reporting," he cautioned in the commentary.

The true rates of wrong-site, wrong-patient surgeries have been hard to come by, Stahel's group agreed. Most databases represent just the tip of the iceberg, including only the most severe, selected cases, they noted.

Their study analyzed a comprehensive, prospective database of 27,370 self-reported adverse occurrences logged by the nearly 6,000 policyholders (31.7% surgeons) of a Colorado professional liability insurance company from Jan. 1, 2002 through June 1, 2008.

Wrong-patient incidents most commonly involved internists (24.0%), followed by family physicians or general practitioners, pathologists, urologists, ob/gyns, and pediatricians, which accounted for 8.0% each.

For wrong-site errors, orthopedic surgeons topped the list, accounting for 22.4%, followed by general surgeons at 16.8%, and anesthesiologists at 12.1%.

Many may be shocked by the high proportion of errors that involved internists, Stahel noted in an interview. However, they and other nonsurgical specialities can be responsible even when they don't make the actual cut, he pointed out.

For instance, wrong dictation on which side needs to be treated or mixing up samples such that the wrong patient is taken to surgery can have its root cause in the medical specialist's or pathologist's office, he explained.

Also, internists "work a lot with needles, drains, and tubes" and do biopsies outside the operating suite -- all procedures, but rarely ever subject to the Universal Protocol safety measures, Stahel added.

In fact, the only death associated with a wrong procedure in the study was a patient who succumbed to acute respiratory failure after wrong-sided placement of a chest tube by an internist.

Nonfatal harm was common, too.

Serious harm occurred in 38 patients (35.5%) subject to wrong-site procedures overall. These included:

Five wrong-level spine surgeries
Four wrong-sided chest tube placements
Four wrong-site vascular procedures
Four wrong-part enterocolic resections
Four wrong-organ resections
Three wrong-site surgeries on the hand or elbow
Three wrong-sided surgeries on the knee or foot
Two wrong-sided ovariectomies
Two wrong-sided eye surgeries
Two wrong-sided craniotomies
Two wrong-sided ureteric procedures
One wrong-sided maxillofacial surgery
Two cases of unintentional irradiation of an untargeted organ outside the oncologic radiation field

Five patients were seriously harmed by wrong-patient procedures (20.0%):

Three prostatectomies performed on wrong patients secondary to mislabeling of biopsy samples
A vitrectomy on the wrong patient because two patients with the same names were coincidentally present in the office
A myringotomy in a child scheduled for an adenoidectomy because the wrong patient was brought to the operating room

The root cause of these errors was communication problems in all of the wrong-patient cases and 48.6% of the wrong-site cases.

The predominant problems leading to wrong-site occurrences were errors in judgment (85.0%) and failure to perform a "time out" (72.0%), the researchers noted.

Errors in diagnosis were a root cause for 56.0% of wrong-patient procedures and 12.1% of wrong-site procedures.

The researchers warned about the lack of a denominator to determine either the rate of wrong-patient, wrong-site errors or the rate of harm associated with them. Another limitation was the possibility of subjective assignment of root causes.
Article source:
By Crystal Phend, Senior Staff Writer, MedPage Today
Published: October 18, 2010
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

Subject: Re: Upcoming procedure? Interesting reading Wed 20 Oct 2010, 1:52 pm

Upcoming procedure? Interesting reading Spiral11

Hello to Dee & everyone!!

I simply cannot even BELIEVE what I have just read above in which Dee posted about the "Upcoming Procedures" & the negligence that the included statistics obviously have proven. That scares me enough to really take into consideration just exactly WHO (what doctor & how well do I know him, as well as how well does he know me?) I would allow any type of procedure on my body without me being "all there" so to speak. (meaning NOT under anesthetic or any mind altering chemicals that do make me feel "out of it" & unable to tell what the doctor is currently doing or rather working on me in the correct place within my body!) I have heard of these type of issues occurring before, yet had NO IDEA of the actual statistics involved in mistreating so many patients. I cannot even imagine going into have this lump removed from my one breast to find out afterwards that they cut the other one off!! And that is not even a fatal condition!! What about these people who have cancer & are being treated with radiation to the wrong parts of their body? Or are going into surgery to have the cancer removed & they remove the wrong organ? Now we are certainly in the ballpark of fatality! Mad

I think that I should take a "time out" (as 72.0% of all doctors should be as well, apparently!) or else I know myself & will go on & on with a ramble that just won't stop when I get so opinionated about such a topic that I feel this passionately about. I believe that doctors should have many more "regulations" than what they do within certain circumstances. They try to hurry, hurry, HURRY through it all (without that time out in between) & although some believe that they are "God" themselves, they are JUST all human, just as we all are, & DO make mistakes. Yet, if they were "forced" to slow down & make that "time out" a requirement to get their "bearings" about them before HURRYING onto the next patient for the $$$$$$$ of it all- how many patients they can possibly squeeze into a day to earn even more $$$$$$$$$, which seems to me to be the root of it all, once again.

Upcoming procedure? Interesting reading Th_dol10

I really will stop about all of this now, but I would like to ask others what they think of this topic that Dee has brought to our attention & what your opinions are regarding these type of mistakes that doctors DO make on a frequent basis. It really made me quite very angry because these doctors are charging us an arm & a leg (maybe literally!) for treatment & they are not even making sure that they are treating the right person or right area of your body!! The time for change is NOW! Please do share your opinions on this matter with us as well. Has anything like this ever happened to any of you that you would be willing to share your story with us? I look forward to any of your responses.

Yours throughout this journey,
~Beth I love you

Subject: Re: Upcoming procedure? Interesting reading Thu 21 Oct 2010, 7:45 pm

Back in December 1996 I had to undergo back surgery to repair a Herniated disc in my lower back. When they take you into surgery you are first placed in a "holding area' where your stay with your assigned nurse until it is time for your procedure.
While waiting to be taken into the O.R. I had an experience that I had forgotten about until now.
There I was waiting and a doctor came to get me, he looked at my nurse and then me and said, are you all set to go. I looked at him and thought it was weird because he WAS NOT my Orthopedic Surgeon but I didn't say anything thinking that my doctor was in the OR waiting for me.
But my nurse spoke up and said, "No, Dr. XXXXX This is not your patient she is the patient of Dr. XXXX (Turned out he was an eye surgeon)
The doctor apologized made a joke and left.
After a few more minutes one of the doctors from my Orthopedics Office approached me to take me into surgery and again the nurse had to tell yet another doctor that I was not his patient.
Twice!! Not once but twice this happened to me that day. Can you imagine?

I had already been given my preanesthetic to relax me and had no idea what was really going on. What would have happened if that nurse hadn't been there with me and I had been asleep? If one of these doctors had succeeded in taking me into the O.R? How far would they have gotten?
Sine then I have had many procedures and I make sure that the doctor in the procedure area is in fact my doctor. I make sure his face is the one I see when I go to sleep. The staff may think of me as paranoid but I don't really care.
I rather be paranoid then mistaken for someone else. I never really thought about it until I read the above article and it happens more than I ever thought.

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