Study Seeks Factors in 'Never-Event' Medical Errors

Communication errors, lack of time-out linked to wrong-person/wrong-site procedures
By Eric Metcalf
HealthDay Reporter

TUESDAY, Oct. 19 (HealthDay News) -- Wrong-patient and wrong-site procedures -- which are surgical "never events" -- may be continuing at a high frequency, according to research published in the October issue of the Archives of Surgery.

Philip F. Stahel, M.D., of the Denver Health Medical Center, and colleagues analyzed data from a physician insurance database covering Colorado physicians, which contained 27,370 physician-reported adverse occurrences from 2002 to 2008.

The researchers found 25 wrong-patient and 107 wrong-site procedures. Significant harm occurred in five wrong-patient procedures and 38 wrong-site procedures, with one patient dying after a wrong-site procedure, which was a wrong-sided placement of a chest tube. The main root causes behind wrong-patient procedures were errors in diagnosis (56 percent) and communication errors (all cases). Wrong-site events were linked to errors in judgment (85 percent) and failure to perform a "time-out" beforehand (72 percent). Non-surgical specialties and surgical disciplines contributed equally to adverse outcomes related to wrong-site events.

"Inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome. On the basis of these findings, a strict adherence to the Universal Protocol must be expanded to non-surgical specialties to achieve a zero-tolerance philosophy for these preventable incidents," the authors conclude.

Several co-authors disclosed relationships with the Colorado Physician Insurance Company, the database used in the study.

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