Surgical Errors

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Surgical events (or surgical errors) are listed by the National Quality Forum (NQF) as a category of “never events” meaning these types of events should never take place in healthcare facilities. The NQF clarifies surgical errors to include:

  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient
  • Unintended retention of a foreign object in a patient after surgery or other procedure
  • Intraoperative or immediately postoperative death in an ASA Class I patient

The impact of surgical errors is significant. Any time an error is made, the potential impact on the patient receiving medical treatment can be life altering or grave. The frequency of surgical errors is low as compared to the number of surgeries performed, but because the effects can be severe, any error is unacceptable. As a result, the NQF’s categorization of surgical errors as “never events” is reasonable.

Some efforts have been made to reduce the number of surgical errors. The Joint Commission created the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ in 2003 (effective July 1, 2004) to “address the continuing occurrence of wrong site, wrong procedure and wrong person surgery” in accredited organizations. This Universal Protocol initially expanded and integrated with the Joint Commission’s 2003 and 2004 National Patient Safety Goals. In 2009, the Joint Commission reviewed and released a new Universal Protocol effective January 1, 2010. The Universal Protocol is checklist for healthcare facilities performing surgical procedures with three principal components guiding the surgical process:

  1. Conduct a pre-procedure verification process
  2. Mark the procedure site
  3. Perform a time-out

The Joint Commission refers to wrong site, wrong procedure and wrong person surgeries as “sentinel events” meaning those involving “an unexpected occurrence involving death or serious physical or psychological injury.” The NQF’s never events (also referred to as serious reportable events or SREs) and Joint Commission’s sentinel events are similar phrases emphasizing the serious negative consequences generated by surgical errors. Both organizations’ classifications are designed to support patient safety.

Checklists Reduce Surgical Errors

The Joint Commission’s Universal Protocol is one example of how simple changes in practice can help alleviate the prevalence of surgical errors. A recent study published in the January 29, 2009 issue of The New England Journal of Medicine discusses the success achieved by the World Health Organization in using a checklist to reduce surgical errors in eight hospitals in diverse worldwide locations. The Surgical Safety Checklist included 19 items “designed to improve team communication and consistency of care” associated with surgery reducing complications and deaths. Results compared 3,733 patients during a baseline period without the checklist and 3,955 after checklist implementation. No significant differences were found between the patients in both groups. Yet, the rate of complication from surgeries dropped from 11% to 7% after implementation of the surgical checklist (P<0.001). Likewise, the in-hospital death rate dropped from 1.5% to 0.8% (P=0.003). These significant results were verified in comparisons between high-income (P<0.001) and lower-income (P<0.001) sites. The results on death rate or complications were retained even with removal of any one hospital site from the data set model (P<0.05). The overall rates of surgical-site infection (P<0.001) and unplanned reoperations (P=0.047) also declined significantly.

These reductions in rates of complications and death suggest that use of a surgical checklist program can improve patient safety. Improvements can be obtained in varying economic and clinical environments. The results also support the researcher’s hypothesis that a program to implement a surgical safety checklist would improve team communication and consistency of care. Healthcare facilities don’t need to invest in expensive technologies in order to decrease surgical errors. Use of a surgical checklist is an inexpensive but proven process improvement. Medical schools may be well advised to modify their training to include use of surgical checklists as part of their training emphasizing the importance of reducing the risk of surgical errors.

Left Instruments – Surgical Errors?

Despite the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ surgical errors often go unreported. Many examples can be found online reporting of doctors commencing operations on the wrong body part or location, and then realizing their surgical error, and then moving onto the correct body part or location. Statistics on the prevalence of surgical errors also does not include information concerning how many times a surgical instrument was accidentally left inside a patient as a result of surgery. The Joint Commission does not include left instruments as part of its definition of sentinel events. Accordingly, one hospital estimates that instruments were left in one of every 5,000 to 20,000 surgical patients (or two to three times a year at that hospital).

Help Prevent Surgical Errors

While research shows that there are cost effective procedures that can be implemented to help reduce surgical errors, patients are well advised to make efforts to protect themselves from the likelihood of a “never event” or “sentinel event”.

  • Ask your surgeon if a surgical checklist is used to help avoid surgical errors. It is appropriate to be concerned about such events and a good surgeon should understand your concern. Introducing this question with your doctor informs them that you have done your homework and facilitates discussion on the other recommendations listed.
  • Discuss the surgery with your surgeon making sure the surgeon is aware of which body part is to be operated on.
  • If appropriate, use a marker to mark the area on your body that is to be operated on (this is “correct”). Likewise, mark the incorrect location (this is “not correct”) if there are two of the same body parts (like a leg, arm, or knee). Have your surgeon initial this marking.
  • Depending on the medical procedure, ask the surgeon if you can remain conscious during the surgery. This will allow you to somewhat interact with surgeon and be partially aware of what is transpiring during the surgery.


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