Reporting Wrong-Site “Surgery”: Errors and Omissions

This morning, four health-reporting websites [New York Times, MedPage Today, CNN Health, Science Daily] reviewed a paper that appears in the October issue of the journal Archives of Surgery entitled “Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era.” The paper documents a number of wrong-site and wrong-procedure incidents from a medical liability insurer’s database in Colorado. The incidents were self-reported by physicians without penalty. It is an interesting study that bears reading but the full on-line version is only available by subscription. So at this time, we only have the abstract of the paper and the reports from the four news organizations to go by.

What strikes me is the manner in which the story is reported. Although the study clearly states that these adverse events were caused by surgeons and non-surgical specialists in equal numbers, three of the four websites headlined the story as follows:

“Wrong Surgery on Wrong Patient Still Happening”
“Surgical Errors Continue Despite Protocols”
“Surgery Mix-Ups Surprisingly Common”

Only one site, Science Daily, used a headline consistent with the title and content of the paper, “Study Documents Wrong-Site, Wrong-Patient Procedure Errors.” That outlet also went into some detail about the percentages of specialists report errors, mentioning that internists were responsible for 24% of the wrong-patient procedures.

A casual reader of one of these articles might assume that these incidents are happening every day. The paper recorded only the submitted events, not the denominator, which would be the number of opportunities to experience an adverse event. The use of a self-reported database is not the same as an epidemiologic study, but only two of the four reports [MedPage Today and NY Times] took the trouble to point this out. The NY Times cited a previous estimate that adverse events such as those documented in the paper occur about once in every 110,000 procedures. This is a serious topic and one which deserves the coverage it is receiving but more accurate reporting and more thoughtful analysis would inform the public better.

There are some other questions about the paper such as how many of these adverse events pre-dated the institution of the universal protocol, which calls for a “time out” and other measures to prevent such incidents. The paper covered the years 2002-2008 and the Universal Protocol was mandated by the Joint Commission in 2004.

I will review the paper in depth for you when I get the full version.