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.
According to the commission's August report, there were 921 wrong-site surgeries reported between Jan. 1, 1995 and June 30, 2010, of which 31 occurred in the first six months of this year. That's more than other leading sentinel events, including hospital suicides, operative or post-operative complications, delays in treatment and medication errors. Wrong site surgery, as a category, makes up nearly 18% of all reported sentinel events.
Just last year at Parkview Community Hospital in Riverside, CA, for example, multiple process errors resulted in a surgeon taking out a patient's right kidney instead of the damaged left one.
According to documents filed by the state, the doctor lacked staff privileges to perform kidney surgery at the time. Additionally, the Spanish-speaking patient was not given an opportunity to give full, informed consent for the procedure, the documents said.
The patient had to undergo another surgery to take out the diseased kidney, and as a result, now undergoes dialysis two-to-three times a week for four hours at a time, the documents said.
Another wrong-kidney procedure occurred at Park Nicollet Health Services, MI a year earlier. And in San Diego, surgeons last year removed the wrong side of the skull of a 93-year-old man in for a brain bleed repair, according to state documents. I could go on.
Now hospitals are gearing up in even bigger ways to prevent such costly and life-altering mistakes, and it can be done, according to the report, "Preventing Wrong-Site Surgery" published by Patient Safety & Quality Healthcare, in collaboration with the ECRI Institute.
In Pennsylvania, where hospitals had a significant wrong site surgery problem, a wrong-site surgery prevention project took shape with funding by Independence Blue Cross and the hospital community, Partnership for Patient Care (PPC), led by the non-profit HealthCare Improvement Foundation.
The group found that the implementation of eight processes reduced the number of wrong-site sentinel events by 72% from the 12-month period starting in October 2007 to the 12-month period from April 2009. Those processes included:
- site markings
- time-outs in between each procedure
- clearing the operating room of any patient information or material that might cause confusion for the next case
The processes included significant detail, including site marking in various stages, such as prior to sedation and done with a discussion with the patient and verified with radiographic information.
The group also conducted unannounced observational assessments of non-emergent surgical cases to help surgeons and their teams identify practices where errors might occur.
"The PPC's regional initiative was successful in accelerating the rate of improvement in preventing wrong site surgery for the participating hospitals," the authors wrote in Patient Safety & Quality Healthcare.
During the same period that this study took place, wrong site-surgery prevention also became a national priority, and the study found that wrong-site surgery events in non-participating Pennsylvania hospitals also declined during the period by 32%.
It surprised me that wrong-site surgery and these near misses are a major component of sentinel events across the country, because I had considered these extremely rare events. And they are, but not as rare as I thought. I am sobered by the discovery and again chagrined that I would even consider joking about such an event.
Moreover, so much the better that concerted efforts now take place to make these avoidable tragedies disappear.
I phoned Averill yesterday to tell him about this column. He remembered my feeble joke—even though it was more than a decade ago. These days at his hospital, he says, there are so many checks at so many points, prior to surgery that the matter of wrong site surgeries remains a very big deal.