Daily life requires some attention to detail. When I drive my car, I’m expected to stay on the right side of the road. Doesn’t make a difference if I spent a month in Ireland driving on the wrong side or if the road isn’t clearly marked as to what side is the correct one. Once I get behind the wheel of a car I’m expected to follow this minimum expectation. If not, well, best case scenario I’ll get a ticket, worst case a head on crash. Details do matter.
That’s why it’s puzzling that healthcare professionals have such a difficult time making sure they operate on the right side of someone. Cutting off the wrong leg, “fixing” the wrong hand, or operating on the wrong side of the brain is considered a “never” event by the Centers for Medicare and Medicaid Services (CMS) as in “this should never happen.” Amazingly, a study published in the April 2006 issue of the journal Archives of Surgery estimates that wrong-side surgeries occur between 1,300 and 2,700 times a year in the United States (3-7 a day).
Horrified? You should be. The problem is not a new one.
A quick Google search shows in 1995 a Florida hospital had two cases of wrong side surgery. In one case the surgeon amputated the wrong leg, another surgeon operated on the wrong knee. In 1996 a surgeon removed the wrong kidney from a patient. In 2007 a California hospital performed three wrong side surgeries in the space of 14 months. In December 2010, a Boston hospital reported three wrong-site spinal surgeries in a two-month period.
You’d think a hospital would learn after the first never event and develop methods to ensure there isn’t a repeat. Wrong. In 2007 a Rhode Island Hospital reported three cases of wrong side brain surgery. If you expect the surgeons involved developed practices to prevent a repeat, you’d be wrong too. Rhode Island neurosurgeon J. Frederick Harrington had already performed a wrong-sided brain surgery in 2006 at another hospital. He repeated his mistake in 2007, even when someone in the operating room questioned whether he was on the right side.
Now, I’m not discounting the universally held, incorrect belief that “it won’t happen to me.” I am sure most surgeons and operating room personnel believe their superior skill, knowledge, and intelligence prevents them from making stupid mistakes. But after the first mistake, do they think lightning can’t strike twice? No use changing the way things are done because it will never happen again? The statistics don’t support that notion.
Because this is an international problem, the World Health Organization (WHO) developed a surgical checklist, also known as a time out. A time for everyone in the operating room, including the patient, to agree on several key things, including the operative side. If properly followed, the checklist would catch errors before they happened and stop wrong site/side surgery for once and all. Unfortunately putting a policy in place, affixing some posters to the locker room, and filling out a checklist gives the illusion of patient safety, but the reality is, even in hospitals with the checklist and time out, wrong side surgery occurs.
Why? Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. Unfortunately, instead of expecting accountability from physicians, hospital strategies to prevent wrong side surgeries include assigning operating room monitors, installing video cameras, and telling the operating room nurse not to hand a knife to the surgeon until the time out is completed.
Wouldn’t it be better if physicians complied because it is a minimum expectation that they operate on the right side of a patient? We can do it on the highway, it’s worth the extra effort in the operating room.