Operations on the wrong body part ‘may be more common than thought’

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Going to the hospital and having an operation performed on your wrong limb may sound like something from a comedy movie. But the mistake may be more common than you think, according to researchers who claimed surgeons don


Operations on the wrong side of a patient’s body ‘may be more common than thought because surgeons are not confessing to their errors’

  • Doctors looked for wrong side errors at 100 Spanish hospitals over a decade
  • They discovered 81 had been recorded during the time frame – 2007 and 2018 
  • However, experts warned this figure was likely just to be the tip of the iceberg

Going to the hospital and having an operation performed on your wrong limb may sound like something from a comedy movie.

But the mistake may be more common than you think, according to researchers who claimed surgeons don’t always confess to their errors.

Doctors tracked how many wrong side error incidents had been reported across 100 Spanish hospitals over the past decade.

They found 81 had been officially recorded during the time frame – but warned this figure was likely just to be the tip of the iceberg.

Going to the hospital and having an operation performed on your wrong limb may sound like something from a comedy movie. But the mistake may be more common than you think, according to researchers who claimed surgeons don’t always confess to their errors

Studies have estimated one wrong side surgery per 100,000 procedures – but the academics suggested the rate may be closer to one in every 16,000.

Dr Daniel Arnal, from the Hospital Universitario Fundación Alcorcón, Madrid, Spain, led the research analysing incidents between 2007 and 2018.

He said: ‘The stark reality is due to the lack of reporting to incident databases, these figures most likely represent an underestimate of the true situation.

‘However, the reporting of wrong side errors have led to substantial corrective measures to prevent their repetition in our hospitals.’

Almost half of the incidents (48 per cent) occurred in orthopaedic surgery, operations on bones, joints, ligaments and muscles.

Ophthalmology surgery – operations on the eye – was responsible for 28 per cent of all of the recorded wrong site errors.

WHAT IS A NEVER EVENT?

Never events represent a fraction of the 4.6 million surgical procedures carried out each year and only occur in one in 20,000 cases of surgery.

They include operating on the wrong body parts, mixing up organs and leaving surgical tools inside patients.

Such incident have even led to deaths, including that of Frank Hibbard, who had undergone cancer surgery in October 2001 at Luton and Dunstable Hospital.

Bungling medics left an 8cm-long piece of gauze inside his pelvis, which triggered a soft tissue cancer and led to the lorry driver’s death, aged just 69.

In 2015, Britain was called out for being one of the worst offenders for leaving items inside patients by the Organisation for Economic Co-operation and Development.

Most of the errors (45) involved anaesthetic being given on the wrong side of the body. Severe harm was caused on three occasions.

The remaining 36 revolved around the surgical procedure itself, according to the study presented at the Euroanaesthesia Congress in Vienna.

An analysis of how the mistakes happened revealed patients were to blame for around 20 per cent, and incorrect site marking responsible for 16 per cent.

Surgeons were distracted in eight per cent of the cases, and rushing was to blame for around 17 per cent of the errors.

The remaining were caused by medics not having a surgical safety checklist, or not using it correctly.

Dr Arnal added: ‘Our findings highlight the need for adequate training and appropriate use of surgical check-lists.

‘While these serious wrong side events are extremely rare, our mission should be to drive them down to zero.’

A never event is defined as a catastrophic hospital blunders deemed so serious that it should never take place, such as operating on the wrong body parts.

To avoid such a blunder, health officials advocate the use of standardised patient wristbands and the World Health Organization’s Surgical Safety Checklist.

The WHO measure, introduced a decade ago, was launched as a tool to improve the safety of surgery and prevent unnecessary deaths.

It helps medics ensure they don’t operate on the wrong patient, perform the wrong procedure or operate on the wrong part of their body.

The data was taken from incidents reported to SENSAR, the Spanish Safety Reporting System in Anaesthesia and Resuscitation.

The database covers 100 predominantly large hospitals across Spain, including one sin the Canary Islands, Madrid and Barcelona.





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