Monday, November 1, 2010

Can Wrong-Site and Wrong-Patient Procedures Be Totally Eliminated?

Last week, MedPageToday asked its readers to answer the question “Can wrong-site and wrong-patient procedures be totally eliminated?” About 70% of the 727 respondents said “Yes.” I say, “No.” Here is why.

The paper from Archives of Surgery, “Wrong-site and wrong-patient procedures in the Universal Protocol Era,” which generated a lot of media interest, contains the answer. The paper is a retrospective study of a medical liability insurance company’s self-reported database of adverse occurrences. There were 25 wrong-patient and 107 wrong-site procedures reported over a 6.5 year period [2002 to mid-2008]. The Joint Commission mandated the Universal Protocol as of July 1, 2004. It called for a pre-procedure verification of the patient, procedure and site, marking of the procedure site and a “time-out” or review of the planned procedure involving all care-givers. According to Figure 3 of the Archives paper, the number of wrong-patient and wrong-site procedures was remarkably consistent over the years of the study which included years before and after the institution of the Universal Protocol. Providers either ignored the protocol or failed to execute it properly.

The factor that will prevent the total elimination of wrong-patient and wrong-site procedures is us. As long as humans are in the equation, human errors will persist.

A recent paper from the British Journal of Surgery entitled “Nature, causes and consequences of unintended events in surgical units,” described 881 self-reported unintended events in 10 hospitals in the Netherlands over a one year period. Human error was the root cause in over 70% of instances, with system errors comprising only 16%. Similarly, an article from San Diego by the leaders of one of the most mature trauma systems in the country, noted a stable rate of complication ocver a 12-year period. While human errors decreased over time, they could not be entirely eliminated. Lack of adherence to guidelines, fatigue, inexperience and other human issues were cited as continuing problems.

Finally, no less an authority than Donald M. Berwick himself has stated “The search for zero error rates is doomed from the start.” [Quoted in Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77:981-92.]

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