Surgical Mistakes Persist Despite Prevention Measures

These are the kinds of mistakes that make you slap your head in disbelief: Surgeons who operate on the wrong patient or on the wrong part of the body (also known as “wrong site” mistakes). In 2004, hospitals nationwide adopted a Universal Protocol that was supposed to prevent wrong-patient and wrong-site surgeries. The protocol consisted of three parts:

  1. A pre-operative/ pre-procedure verification process, which includes looking at patient identification and confirming with patient records
  2. Marking the operative/procedure site, which should involve the patient, if possible. This means actually writing on the patient’s body with a marker. For example, if surgery is to be on the left shoulder, then the left shoulder should be marked “YES,” and the right shoulder marked “NO.”
  3. A Time Out (final verification) which is performed immediately before starting the operation/procedure. This involves verifying that the patient on the table is the correct patient, that the procedure is the same as the one in the records, that the marked site is the one prepped for surgery, and any other necessary information is confirmed.

With all these requirements in place, how can mistakes possibly happen anymore?

Some scientists asked that same question, and published the results of their inquiry in the October 2010 issue of the Archives of Surgery. Here’s what they found:

During the 6.5 years of the study, there were more than 27,000 clinician-reported “adverse events,” or problems. Of these, 25 wrong-patient and 107 wrong-site procedures were identified, many of which caused significant harm to the patients, including one death.

According to a report of the research by ScienceDaily, the causes of wrong-patient procedures were errors of communication, and the causes of wrong-site procedures were due to lack of clinician judgment and not performing the third step of the Universal Protocol, the “Time Out.”  According to the researchers:

Inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome. On the basis of these findings, a strict adherence to the Universal Protocol must be expanded to non-surgical specialties to achieve a zero-tolerance philosophy for these preventable incidents.

Lessons for Patients

The results of this research are frightening. Anyone who has ever had surgery knows that helpless feeling as you surrender yourself into the hands of the nurses, anesthesiologist, and surgeon. It requires a certain amount of trust… and yet, this study suggests that we also need to bring our assertive nature to the hospital with us.

  • If you see or hear something that sounds wrong, speak up. Don’t assume that the doctors or nurses will discover the “truth” later.
  • Mark your own surgical site before you arrive at the hospital.
  • Make yourself a simple “Surgical Name Tag” that you can wear around your neck. Include your name, your diagnosis (if known), the site or type of surgery you are supposed to have. For example, it can be as simple as: John Doe, torn rotator cuff, left shoulder. Keep the tag on for as long as the hospital personnel allow.
  • Ask to speak with the surgeon before the surgery to confirm the procedure. It is possible that you might not meet the surgeon until you are wheeled into the operating room, but even that affords you just enough time (before anesthesia is administered) to confirm your name and surgery site and type.

And if the worst happens and you are the victim of wrong-site, wrong-patient, or other hospital error? Contact a law firm in your area that is experienced in handling these types of medical malpractice cases. HensonFuerst Attorneys built their reputation on helping people injured by doctors, hospital personnel, and other medical problems. That’s why our phone number is 1-800-4-LAW-MED. If you’ve been injured and want to discuss your individual situation, call us. There’s someone here 24 hour a day. Or visit our website at If you have questions, HensonFuerst has answers.


To read the Patient Safety Refresher, including the Universal Protocol procedure, click here: Stanford Hospital & Clinics Universal Protocol

To read the abstract for the journal article, click here: Archives of Surgery

To read a great summarizing report about the research, click here: ScienceDaily

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