NCPA - National Center for Policy Analysis


April 18, 2006

Despite years of patient-safety efforts, an increasing number of health care facilities have reported mistakenly removing the wrong limbs or organs, slicing into the wrong side of bodies and performing surgery on the wrong patients.

And the situation is getting worse, says Dennis O'Leary, who heads the non-profit Joint Commission on Accreditation of Healthcare Organizations, which inspects more than 15,000 hospitals and surgical centers nationwide and sets patient safety requirements and guidelines.

  • Last year, health care facilities reported 84 operations to the commission that involved the wrong body part or the wrong patient.
  • While some states require hospitals to report such blunders, many hospitals across the nation are not obligated to account for them publicly.

A new study funded by the federal Agency for Health Care Research and Quality documents cases in which surgeons operated on the wrong arm, the wrong rib and in one case the wrong person, among other mistakes.

The study of 2.8 million operations over a 20-year period, published in the Archives of Surgery, suggests that the rate of "wrong site" surgery anywhere other than the spine is 1 in every 112,994 operations. The study excludes the spine, the authors explain, because surgical sites on the spine are verified with X-rays, in contrast to the apparent simplicity of marking the correct knee or ear in advance.

The researchers conclude that the rate is "exceedingly rare" but "unacceptable."

Patient safety experts say more vigilance is needed. "We're trying to get the number down to zero," says Donald Palmisano, a New Orleans surgeon on the nonprofit National Patient Safety Foundation's board of directors. "It is such a catastrophe when this happens."

Source: Robert Davis, " 'Wrong site' surgeries on the rise," USA Today, April 18, 2006; based upon: Mary R. Kwaan et al., "Incidence, Patterns, and Prevention of Wrong-Site Surgery," Archives of Surgery, Vol. 141 No. 4, April 2006.

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