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Wrong Site Surgeries Still a Threat

Cheryl Clark, for HealthLeaders Media, October 14, 2010

My runner's knee had called it quits. No more 10Ks for me.

So I limped to Robert Averill MD, an orthopedist known for his skill in joint repair. "A cyst," he announced with a smile when the X-ray clicked against the light. "The biggest I've ever seen!" he joked.

Yes, I would run again soon, he promised.

Later, as I awaited anesthesia in the hospital, the pre-op nurse leaned over. "You'll need to mark your leg so we make sure to get this right," she said. Then she handed me a black skin-marking pen.

As I woke up, Averill came by with a smile: the cyst was out, the knee was clean and the operation a success. He handed me a CD of the video "in case you want to watch."

"Thanks, Dr. Averill," I said with a groggy grin. "But why is my right knee bandaged!?"  

Averill's face seemed to drop from his brow to his jaw and his eyes expressed horror. I remember wishing I could retrieve my childish joke mid-air. My lame, fumbling words to reassure him fell flat.

Only later did I learn that another surgeon in town had heard the same patient's words a few weeks earlier, and that patient wasn't joking at all. In later years when I ran in to Averill at the store, I continued to apologize for my unenlightened gaffe.

It certainly is not a joke in any hospital or physician's practice.

With increasing attention on never eventsand hospital-acquired conditions, public reporting, and accompanying financial penalties, it's no wonder so many healthcare facilities are taking extraordinary measures to make sure such mistakes are rare, if not impossible, to make.

Yet wrong site/wrong side surgeries still happen, a lot more than many OR teams acknowledge. It remains the leading sentinel event identified by the Joint Commission, varying in severity and consequence from the wrong leg receiving anesthesia to more consequential incidents in which the wrong organ is removed.

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1 comments on "Wrong Site Surgeries Still a Threat"


Gretchen Hammer (10/15/2010 at 8:48 AM)
The coming opening of our newly renovated operating room was the perfect time for our hospital's Quality Improvement Patient Safety Committee to be updated on OR policies/procedures. We were delighted to learn that we have many checkpoints installed in the surgical unit, including Time-Out, when each member of the OR team announces who s/he is and what the procedure is for the day, as well as what that person's role is....