Antiquated Antidotes

Just a few short years ago surgery was performed on a 15 year old male to remove the epileptic foci from the right side of his brain that had been causing a seizure disorder. It wasn’t until after the surgery had begun that the medical staff realized that they were operating on the left side of his head rather than the right. The team decided to carry on with the surgery and shifted their focus to the correct portion of the brain only after making unnecessary cuts to the left (Lin). The damage had already been done though. The boy would develop cognitive problems and severe personality changes as a result of wrong-site surgery. His parents filed a suit and were awarded $20,000,000.00 (Lin).

 Wrong-site, wrong-procedure, wrong-patient surgical mishaps, although infrequent, do still occur in the 21st century. They are classified as “never-events,” because they should never happen, yet it is estimated that hospitals experience at least one instance of a related case every 5-10 years (“Wrong Site”). Some studies have shown that it occurs in about 1/112,000 procedures but the data may be skewed by the states who do not require such events to be reported to the medical boards (“Wrong Site”). What are the repercussions of these “never-events” and what are medical professionals doing to prevent future occurrences?

Effects of Surgical Mishaps:

Wrong site surgeries have the potential to completely destroy patient-surgeon trust. Also, they obviously cause the patient both physical and mental anguish and have the potential to result in unnecessary complications and even death. In many cases malpractice suits are filed and they can cost the hospitals a lot of money.

 One example of a patient having to get additional surgeries as a result of wrong-site surgery occurred when Dr. Charles Coonan Streit, an expert in Urology, removed the healthy kidney of his 50 year old patient in 2014 (Coker). The diseased kidney was left inside of his body and he had to undergo 2 other procedures. Dr. Streit received 3 years probation from the medical board after having his license for 41 years without such an incident. He claims that the patient’s medical records that he had received were incomplete. St. Jude Medical Center in Fullerton, where this took place, now ensures that accurate medical scans are provided to the surgeons on the day of surgery so that they do not have to rely on their memory (Coker).

        Not only do hospitals try to supply their professionals with accurate records, but they also encourage staff members to use the “sign your site” practice with all invasive procedures. Surgeons physically mark up the area of the body about to be operated on. This is not a perfect solution though because there have been cases where the surgical team was unsure whether a marked site meant it was the spot being operated on or whether it was used to mark the spot with which to leave alone. 

        A very effective method that most hospitals utilize is known as a “time-out.” It is a period of time where the entire staff pauses before beginning an operation to take a breather and ensure that they have all of their information correct and are on the same page with what will be taking place in the operating room(“Wrong site”). One other main preventive to wrong-patient occurrences is simply verifying who the patient is and  having them say specifically who they are and what they are there for that day. It seems simple to not mix up patients but names and cases can look the same if a physician is in a hurry or overwhelmed. 

“There is a big difference between hospitals that take care of patients and those that take care of doctors.”

Until Next Time,

N.F.

Sources:

• Boodman, Sandra G. “The Pain of Wrong Site Surgery.” Washington Post. 20 June, 2011. Accessed 27 September, 2021. washingtonpost.com/national/the-pain-of-wrong-site-surgery/2011/06/07/AGK3uLdH_story.html.
• Coker, Matt. “Dr. Charles Coonan Streit Disciplined By Medical Board for Removing Wrong Kidney.” OCWeekly. 4 December, 2014. Accessed 27 September, 2021. ocweekly.com/dr-charles-coonan-streit-disciplined-by-medical-board-for-removing-wrong-kidney-6483749/.
• Lin, Andrew and Brian Wernick, Julia C. Tolentino, and Stanislav P. Stawicki. “Wrong-Site Procedures: Preventable Never Events that Continue to Happen.” Intechopen. 10 January, 2018. Accessed 27 September, 2021. intechopen.com/chapters/55620.
• “Wrong-site, Wrong-procedure, Wrong-patient Surgery.” PSNET. 9 September, 2019. Accessed 27 September, 2021. psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery.