What is “High Reliability?" Harris Health System will become a high-reliability organization (HRO) with quality and patient safety as its core values where ZERO HARM is not only a possibility, but an expectation. So what is High Reliability?
In July 2021, University Hospitals, in Cleveland, Ohio, announced that its staff had transplanted a kidney into the wrong patient. In April 2020, an interventional radiologist at Boca Raton Regional Hospital, in Florida, was sued for allegedly placing a stent into the wrong kidney of an 80-year-old patient. Using fluoroscopic guidance, the doctor removed an old stent from the right side but incorrectly replaced it with a new stent on the left side.
Wrong-site surgery ― surgery performed on the wrong patient, the wrong body part, or the wrong side of the body ― is a rare but distressing event and garners much attention when it happens.
"The problem is that it is so rare that doctors don't focus on it," says Mary R. Kwaan, MD, a colorectal surgeon at UCLA Medical Center, Los Angeles, California.
A 2006 study estimated that 25 to 52 wrong-site surgeries were performed each week in the United States. In 2013, 2.7% of patients who were involved in wrong-site surgeries died and 41% experienced some type of permanent injury. The mean malpractice payment was $127,000. Some malpractice payments are much higher. In 2013, a Maryland ob/gyn paid a $1.42 million malpractice award for removing the wrong ovary from a woman in 2009. In 2017, a Pennsylvania urologist paid $870,000 for removing the wrong testicle from a man in 2013.
Wrong-Site Surgery Often Involves Experienced SurgeonsOne might think that wrong-site surgeries usually involve younger or less-experienced surgeons, but that's not the case; two-thirds of the surgeons who perform wrong-site surgeries are in their 40s and 50s, compared with fewer than 25% younger than 40.
In a rather chilling statistic, in a 2013 survey, 12.4% of doctors who were involved in sentinel events in general had claims for more than one event. In a study reported in the Journal of Neurology, Neurosurgery and Spine, 25% of orthopedic surgeons reported performing at least one wrong-site surgery during their career. Within orthopedics, spine surgery is ground zero for wrong-site surgery. "Finding the site in spine surgery can be more difficult than in common left-right orthopedic procedures," says Joseph A. Bosco III, a New York City orthopedist.
It's Not Just the Surgeon's Mistake Mistakes are not only made by the surgeon in the operating room (OR). They can be made by staff when scheduling a surgery, radiologists and pathologists when writing their reports for surgery, and by team members in the OR. Many people are prone to confusing left and right. A 2020 study found that 14.9% of people had difficulty distinguishing left from right; other studies have shown higher rates. Distractions increase the likelihood of mistakes.
A Push to Eliminate Wrong-Site Surgery In 2009, the Joint Commission encouraged hospitals to make root-cause analyses not only of wrong-site surgeries but also of near misses, which are much more plentiful. It used the insights gained to change surgical routines and protocols. The Safe Surgery Project, a collaboration between the Joint Commission's Center for Transforming Healthcare and eight hospitals and surgery centers, reduced the number of errors and near misses by 46% in the scheduling area, 63% in pre-op, and 51% in the OR area.
Changing the Culture Reformers argue that wrong-site surgeries can be prevented by changing the culture of the hospital or surgery center. "We have to think of wrong-site surgeries as a failure of the system, not of the individual," says Ron Savrin, MD, a general surgeon in Chagrin Falls, Ohio, who is a surgery subject matter expert for the Sullivan Group. "It should never be only up to one individual to stop an error from occurring." Seeing oneself as part of a team can reduce errors. Wrong-site surgeries are often concentrated in certain hospitals ― even prestigious teaching hospitals are not immune. A decade ago, Rhode Island Hospital had five wrong-site surgeries in two years, and Boston's Beth Israel Deaconess Medical Center had three wrong-spine surgeries within two months.
The Goal Is Zero Errors Because reported information is spotty and no major studies on incidence have been conducted in recent years, "we don't have a clear idea," he says, "but my best guess is that the rate is declining. Absolute zero preventable errors has to be our goal," Savrin says. "We might not get there, but we can't stop trying.”
Note: Adapted from “MDs Doing Wrong-Site Surgery: Why Is It Still Happening?,” L. Page, Sept. 29, 2021, Medscape Medical News.