Medical mistakes are an unhappy reality

A surgical team at Northside Hospital was supposed to remove one of the patient’s breasts — but performed a double mastectomy because of a mistake, state records show. At Atlanta Medical Center, a surgeon drilled into the wrong side of a patient’s head before discovering the error.

At several Georgia hospitals, doctors circumcised the wrong babies, performing the procedure against their parents’ wishes in cases at Wellstar Kennestone Hospital and Cartersville Medical Center. At others, doctors mistakenly operated on the wrong hand, knee, hip, leg, hernia and other body parts.

Protecting yourself
Patients need to take an active role to prevent medical errors. Some tips:

• Talk with your doctors: Make sure you, your doctor and your surgeon agree on exactly what will be done.
• Read paperwork: When signing consent forms and working with schedulers, make sure they all have the correct information about the surgery, including which side is to be operated on.
• Have an advocate: Designate someone to be with you for the surgery to help ask and answer questions.
• Get marked: Make sure your doctor marks on your body the correct site for the surgery prior to the operation.
• Encourage questions: When hospital workers repeatedly ask you to verify your name and your procedure, don't get frustrated. It's a sign they're doing their job.

Where to complain

Georgia Department of Human Resources: Accepts reports about serious health and safety issues involving hospitals. File a complaint online or call 404-657-5726. Composite State Board of Medical Examiners: Investigates complaints about licensed health care providers. Call 404-656-3913 or go online.
SPOTLIGHT: BY ALISON YOUNG

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No comprehensive national data are available to know how often “wrong-site” surgeries occur. Experts say they’re rare but should never happen. In Georgia they occur on average more than once a month, data indicate.

Yet despite protocols required by the Joint Commission, a national hospital accrediting organization, and years of initiatives by medical groups, the problem persists here and across the country.

Regulators at the Georgia Department of Human Resources have received 102 reports of wrong-site surgeries since 2003, when reporting the incidents became mandatory. Since July 1, the state has received 20 reports. It received 15 in fiscal year 2008.

“What I would suggest for patients is not to assume or presume that their health care provider is getting it right,” said Dr. Peter Angood, senior adviser for patient safety at the National Quality Forum, a leading nonprofit health care organization whose members include consumers, medical professionals and insurers.

The basic steps to prevent wrong-site surgeries should be well known to surgical teams: Verify the patient, mark the surgical site and take a “time out” in the operating room — right before the incision — to check records one last time to ensure that the procedure is what’s been ordered.

But in the real world of operating rooms, Angood and other experts said, it can be difficult to get surgeons, nurses, anesthesiologists and others to work together.

“In many cases they’re preventable, and therefore there’s no room to tolerate them,” said Dr. James Barber, a surgeon in Douglas and a spokesman for the American Academy of Orthopaedic Surgeons. The group has campaigned for years for surgeons to write their initials at the incision site.

Officials at several Georgia hospitals said patient safety is their priority, and they follow the Joint Commission’s “universal protocol” of steps to prevent wrong-site surgeries.

“The public has the right to expect perfection,” said Dr. William Bornstein, chief quality officer at Emory Healthcare. He noted that wrong-site surgeries are rare and much less a risk than the potential for medication errors or health care-associated infections.

Bornstein declined to discuss specific wrong-site incidents at Emory hospitals or say how many had occurred. In 2007, records show, the state cited Emory Crawford Long Hospital in Atlanta after a doctor circumcised the wrong baby and hadn’t reviewed records — which lacked parental consent — before the procedure. Also in 2007, a surgeon at Emory Eastside Medical Center in Snellville began surgery on a patient’s left knee — even though the right knee had been marked as the one needing the procedure.

How often such incidents occur at Georgia hospitals — and whether some hospitals are more prone to the events than others —s kept secret. The Georgia statute that requires hospitals to report all wrong-site surgeries also specifies that the state will keep the details confidential.

Only when a state investigation finds violations of regulations — such as evidence the hospital doesn’t have good procedures to prevent wrong-site surgeries — are some records made public. Incidents that involve isolated mistakes and occur despite hospital policies cannot be made public under state law.

“We review each one of those reports in detail,” said Sharon Dougherty, director of the state Office of Regulatory Services, which oversees hospitals. If the hospital’s report raises concerns, state officials will do a monitoring visit, she said.

In February regulators cited the Atlanta Medical Center where a surgeon mistakenly began drilling into the wrong side of a patient’s head. A brain scan of the patient, an emergency case, showed swelling on the right side due to a broken blood vessel. Yet initial incisions were made on the left side; while drilling, the unnamed surgeon realized it was being done on the wrong side.

Atlanta Medical Center officials declined to discuss the case, but said they are committed to patient safety and this was the only wrong-site incident the medical center has reported to the state in three years.

In late 2007 at Northside Hospital in Atlanta a double mastectomy was performed on a patient who was scheduled to have the left breast removed. Another surgeon was then supposed to perform reconstructive surgery on the left breast and reduce the right breast.

The left breast, the intended site for the first surgery, was marked and a “time out” was performed, staff told investigators. But the position of the surgical table was changed and the surgery started on the right side by mistake, records show. The error was discovered after the surgeon had removed the wrong breast.

Northside Hospital officials declined to discuss the incident; nor would they say how many other wrong-site incidents the hospital has reported. “These types of incidents are extremely rare,” the hospital said in a statement.

Last August at Wellstar Kennestone Hospital in Marietta, a doctor mistakenly circumcised the wrong baby and his parents had chosen not to have the procedure done. Wellstar officials, who said they have a comprehensive patient safety program, declined to discuss specific incidents.

In January, the same thing happened at Cartersville Medical Center. Regulators cited the hospital for failing to do a “time out” to check that the doctor had the right baby. The parents didn’t want the procedure done, records show. “We extended our sincere apologies to the family” and retrained all staff, the hospital said.

It’s unclear what consequences doctors and surgical team members face when wrong-site procedures occur. Disciplinary actions taken by hospitals are private.

Officials at the state medical licensing board said they were unfamiliar with of some of the cases described in the records obtained by the AJC, such as the one involving the double mastectomy.

It could be that complaints weren’t filed against the doctors’ licenses because errors were the result of system problems and involved many employees, said Dr. Jim McNatt, medical director of the Georgia Composite State Board of Medical Examiners.

Wrong-site complaints to the board more commonly involve surgery on the wrong part of the spine than on the wrong hand or other external body part, he said. McNatt encouraged patients to report incidents to the board.

It’s also unclear whether Georgia hospitals report all wrong-site procedures to the state, as required. State regulators said they think the 15 or so reports they get a year are everything, but they have no way to be sure.

By comparison, there were 76 reports of wrong-site incidents filed with state watchdogs in Pennsylvania last year, about four times the number in Georgia. Pennsylvania has just 30 percent more residents than Georgia.

In Pennsylvania, the state created an organization focused on collecting, analyzing and informing the public about patient safety issues. “We get roughly a report a week,” said Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority. He said there’s no reason to believe wrong-site surgeries happen more in his state. “We calculate that you could expect a wrong-site surgery in a 300-bed hospital roughly once a year,” he said.

How we got the story

Under the Georgia Open Records Act, the AJC obtained copies of 27 complaint investigation reports where hospital regulators cited wrong-site surgery problems since 2004. The records — which do not identify patients, doctors or nurses — represent only about one-third of the total incidents reported to the state by hospitals during that period.

Self-reported incidents that did not result in a violation finding — even though a wrong-site incident occurred — are kept secret under state law.

Check our sources

Look up inspecton reports for Georgia hospitals, including those in this article, at www.ors.dhr.state.ga.us

What the reports show

Here are some other incidents from state regulatory files:

Piedmont Hospital: In December, regulators cited the hospital for performing an “invasive procedure” on the wrong leg of a patient. In 2006, the Atlanta hospital was cited after a surgeon started doing surgery on the wrong knee. The correct, right knee was marked, but after anesthesia was administered, a surgical assistant prepped the wrong knee. The surgeon then entered the room, said “left knee” a couple of times, then made the incision before the nurse double-checked the records. Hospital officials declined to discuss the incidents.

Wellstar Cobb Hospital: In late 2008 a patient was given a post-surgical anesthetic nerve block in the wrong leg. In 2005 a doctor performing cataract surgery at the Austell hospital implanted the wrong lens in a patient’s eye. The mistake occurred when the order of two patients’ surgeries was changed.

Memorial Health University Medical Center: In 2008 a patient had an order for a colonoscopy, an exam of the large intestine. But instead, a doctor at the Savannah hospital performed a different procedure that involved putting a flexible tube down the patient’s throat to examine the esophagus and stomach. Hospital officials were unavailable for an interview.

Northlake Medical Center: The top of a patient’s left foot was marked “YES” as the appropriate surgical site in a 2005 incident. But the patient was put onto the operating table lying face down. Doctors at the Tucker hospital then administered a nerve block to the right foot and after making an incision they realized it was the wrong foot.

• Only when a state investigation finds violations of regulations — such as evidence the hospital doesn’t have good procedures to prevent wrong-site surgeries — are some records made public. Incidents that involve isolated mistakes and occur despite hospital policies cannot be made public under state law.