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Surgeries on the wrong-side could be prevented if doctors would own up to their errors


It’s the stuff of horror movies: A patient enters the hospital for a routine surgery – perhaps the removal of his appendix – and wakes up after the surgery to discover that an entirely different body part has been removed – perhaps his kidney.

With the reams and reams of forms that patients are required to complete before undergoing surgery it is logical to assume that the above scenario would be virtually impossible in a modern hospital environment.

Nonetheless, recent research presented at the Euroanaesthesia Congress – the annual meeting of the European Society of Anaesthesiology – indicates that procedures mistakenly performed on the wrong part of a patient’s body are far more common than previously thought.

Even worse, these errors are almost entirely preventable, and are very often the result of surgeons lacking the humility to double check themselves, to slow down or to admit their mistakes. (Related: BOTCHED: Surgeons rarely apologize for horrific mistakes made during surgical procedures … They usually try to cover them up.)

Surgical blunders far more common than previously believed

According to the researchers – who examined data reported to SENSAR (the Spanish Safety Reporting System in Anaesthesia and Resuscitation) – about 81 wrong side errors (WSEs) were reported in 100 Spanish hospitals in the period between 2007 and 2018.

About half of the reported incidents took place during orthopedic surgery, while operations on the eye (ophthalmology) accounted for close to a third of the total number of incidents reported. Around 45 percent of the incidents involved anesthetic being applied to the wrong side of the body, with serious harm resulting in three of the procedures. (Related: Woman lived with pair of eight-inch scissors in stomach for three years following surgical error.)

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As horrifying as the study’s findings were, however, experts believe that this research represents only “the tip of the iceberg.”

As reported by the U.K.’s Daily Mail, earlier studies have indicated that only one WSE takes place for every 100,000 procedures, however, experts now claim that the real statistic is around one in every 16,000 procedures.

Dr. Daniel Arnal, of the Hospital Universitario Fundación Alcorcón in Madrid, Spain, warns that there is a serious lack of reporting on incident databases, making the official figures unreliable.

So, why so many easily preventable errors?

The Mail reported:

An analysis of how the mistakes happened revealed patients were to blame for around 20 per cent, and incorrect site marking responsible for 16 per cent.

Surgeons were distracted in eight per cent of the cases, and rushing was to blame for around 17 per cent of the errors.

The remaining were caused by medics not having a surgical safety checklist, or not using it correctly.

Clearly, the research indicates a need for more training and better adherence to surgical checklists, if so-called “never events” – catastrophic events like operating on the incorrect body part, which should never take place – are to be prevented.

Around a decade ago, the World Health Organization (WHO) introduced a system whereby patients have to wear special standardized wristbands and surgeons have to strictly adhere to the WHO’s Surgical Safety Checklist. These measures have borne fruit but have not been enough to eliminate the problem of never events entirely.

“Our findings highlight the need for adequate training and appropriate use of surgical check-lists, as well the creation of a standardised surgical site marking protocol, the correct revision of clinical history and imaging tests, and involving patients in their own safety,” noted Dr. Arnal. “While these serious wrong side events are extremely rare, our mission should be to drive them down to zero.”

Learn more about the dangers and complications of surgery at Medicine.news.

Sources for this article include: 

DailyMail.co.uk

EurekAlert.org



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