Surgical Mistakes Continue in Spite of Universal Protocol

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A new study published this month in the Archives of Surgery note that surgical mistakes and errors continue to plague the healthcare system in spite of the Joint Commission’s 2004 implementation of a universal protocol designed to avoid such errors.
“What is shocking about the data is that each and every one of those wrong-site, wrong-patient errors is really an event that should never happen,” said study author Dr. Philip F. Stahel, a visiting associate professor at the University of Colorado School of Medicine in Denver.
“These happen much more frequently than we think. This is just the tip of the iceberg,” he said. “Introducing the universal protocols have not reduced the frequency of these events.”
Stahel believes that diagnostic errors and poor communication are the culprits behind the surgical errors. According to his study, operations on the wrong body part are due to errors in judgment 85% of the time while 72% of the time errors occur due to a failure to adhere to the “time-out” prior to surgery as mandated in the universal protocol. He believes a system of checks and balances cannot replace personal accountability. “We are going from a culture of blame to a culture of system safety, and we should move on to a culture of patient safety and accountability,” he said.

Kevin Dugan
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