Wrong site surgeries and procedures happen as many as 40 times each week in U.S. hospitals, Joint Commission safety experts acknowledged in a recent teleconference.
Of course, most of these wrong site procedures go unreported, because not all states have laws requiring notification. And many may be less consequential and more easily remedied, for example, arthroscopic surgery of the wrong knee, as opposed to removal of the wrong kidney.
But some of these errors are very serious and so, serious prophylactic actions must be taken.
Could video recording surgeries be a solution?
It appears that some healthcare providers are considering this idea to identify errors, or at least earmark flaws in their processes, that could lead to wrong site surgery.
Then again, using video cameras to record surgeries may be an idea that has the potential of going too far.
Massachusetts Rep. Martin Walsh, D-Dorchester, has introduced a bill he calls "Leona's Law" which would require hospitals to allow a licensed medical videographer to record a patient's surgery – at the patient's or family's request – or face a $10,000 fine. The patient or family – not the hospital – would have to foot the bill.
"I had a constituent whose mother passed away during a routine surgery, and he said he never got the answer he should have about why. So he came up with the idea of placing a video camera in the operating room," Walsh explained in a telephone interview.
"The idea had legs, but the hospital association and others were opposed, pointing to liability issues, and that it's an expense to the hospital, because it would have to wire the operating rooms," he says.
But the bill remains viable, despite that opposition. Walsh says using video recording could provide a way for the patient or family "to review what happened in the operating room in the event of a complication."
"There's going to be a lot of discussion of how this could be a useful tool for hospital administrators," Walsh continues. "I know that a lot of people are looking at this as an obstacle but at the end of the day, this could emerge as a positive tool to prevent errors.”
In Rhode Island, state health officials have issued a consent decree for 719-bed Rhode Island Hospital in Providence to begin using cameras in the operating room after five wrong-site surgeries occurred there between 2007 and 2009. Each of the hospital's 379 surgeons must be recorded on video during two of their procedures each year, and they don't know when those times might be.
The randomly assigned cameras have been streaming operations live so they can be seen in realtime by an observer in another room. No digital or print records are kept.
Additionally, hospital nurses conduct random audits of surgical procedures to make sure that the surgeons are conducting appropriately scripted time-outs.
"Every (surgeon) knows the potential that they could be on video, but we don't notify them ahead of time," said Mary Reich Cooper, MD, senior vice president and chief quality officer for Lifespan Corp., which includes Rhode Island Hospital.
However, Cooper does not suggest that hospitals rush out to install these systems anytime soon. And neither do I.
"Our staff have been very comfortable with the video cameras being in place, but we would not encourage them to be used like they are in casinos, like they are an eye in the sky and an extra set of eyes all the time," she says.
Rather, she explains, "We rely on the staff for policing, correcting, and auditing themselves to make sure that everyone in the room is complying with the scripts that we have written for the staff to use during the time out process," Cooper says.
Mike Sise, MD, vascular surgeon and head of trauma at Scripps Mercy Hospital in San Diego, says that videography for training and quality purposes used to be routine for Mercy's resuscitations until the late 1990s, when staff realized they might be putting patient privacy at risk. Trauma settings have done it for training and quality control purposes for decades.
But for experienced trauma systems and teams, routine use of the camera seemed less valuable. "You have to realize that anything [recorded on video] can get out, and then you have a significant ding on your privacy that has nothing to do with quality or whether we did a good job. It's going to be on YouTube or whatever," says Sise.
There may be a way around the privacy concern, however, if, as at Rhode Island Hospital, the video captures are not saved.
Nevertheless, Sise adds, use of a video camera is like using a blunt instrument when a sharp scalpel might be a strategically effective tool to prevent errors. "It's like using drug testing for teenage drug use. There's no substitute for good parenting," he says. Far better, he suggests, is the team's need to recognize the three highest risks for surgical errors: fatigue, familiarity, and distraction.
At Rhode Island Hospital, Cooper says that root cause analyses pointed to errors being multi-factorial with the level of surgical complexity and bilateral surgeries at the top of that list.
And, she says, since the process began there have been no wrong-site surgeries or close calls, but she emphasizes that it's not the videography that's completely responsible for the hospital's improvement.
Rather, she believes, what's different is a culture change that she and quality officials from four other hospitals and three ambulatory care centers have achieved, in collaboration with the Joint Commission's Center for Transforming Healthcare.
"We give employees and front line staff the opportunity to speak up and say so whenever they're uncomfortable with a situation or direction," she says.
Mark Chassin, MD, president of the Joint Commission, also discouraged hospitals from making a massive jump to employ videography in the surgical suite.
"There are a lot of process that takes place prior to the patient's arrival in the operating room, and those parts of the process need to be perfected as well as the last part of the process in the operating room," he says. "I don't think it (videography) is a necessary step. And, as Mary [Cooper] suggests, it can be helpful if individual organizations think that kind of auditing or additional information could help them pinpoint problems.”
The eight organizations that participated in the wrong-site surgery examination process "have shown that we can identify areas where the risk of this problem is introduced ... and we can develop tools to drastically reduce that risk without having to invest in a huge number of video cameras," Chassin said.
The task force identified high-risk practices that Cooper and others believe are far more important to change if surgical errors, such as wrong-site surgery, are to be fixed. Some of these practices have nothing to do with what happens in the hospital at all.
As Chassin says. A beginning-to-end examination needs to occur. Errors creep into the process in the physician's office when the patient is being scheduled for surgery and during the transmittal of the patient's record from a nurse or clerical employee to the hospital surgical scheduler. Then, there are opportunities for error in the pre-operative phase of the patient's visit.
The toolkit developed by the Joint Commission effort lists 29 scheduling and surgical practices that put hospitals and their patients at higher risk for a error such as wrong-site surgery.
And after each flaw, the toolkit enumerates remedies to remove those risks. And it's a long one. But Cooper and others say that fixing these problems, much more than installing eyes in hospital surgical suite ceilings, will be much more likely to reduce mistakes.
I say that if a family member or a patient insists on a video camera, let them have it and let them pay the additional cost. But for now, there are much better ways to stop surgical errors by making it almost impossible for them to happen in the first place.