A Colorado study published late last year found that the incidence of surgeons operating on the wrong patient or at the wrong site is still high despite national efforts to improve compliance with the Universal Protocol, which specifies preprocedure verifications, surgical markings, and a "time out" before starting surgery.
Researchers found that over a six-and-half-year period, Colorado physicians reported 25 wrong-patient and 107 wrong-site procedures to a liability insurance database. The Universal Protocol has been in effect since 2004.
Failure to comply with one of the steps in the Protocol was the cause of the surgical error in a large number of the cases in the study. Interestingly, nonsurgeons were as likely as surgeons to be the cause of the error.
One death was reported when a patient died from acute respiratory failure due to wrong-sided placement of a chest tube.
Thirty eight patients suffered serious harm as a result of wrong-site procedures. These included:
Five patients were seriously harmed by wrong-patient procedures:
Click here to read more about the study on MedPage Today.
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