Reminder to Cinical Lab Managers and Pathologists that Patient Safety is a High Profile Issue
It’s a powerful reminder of how the patient safety movement has elevated awareness of medical errors. Recently, Rhode Island Hospital was fined a whopping $150,000 for performing the wrong operation on the wrong finger of a patient. The fine was assessed by the Rhode Island Department of Health.
This was Rhode Island Hospital’s fifth wrong-site surgery (WSS) in two years. The hospital, which is the state’s largest hospital and is also the teaching hospital for Brown University’s School of Medicine, was fined $50,000 in 2007 after brain surgeons operated on the wrong part of the head in three patients.
In response to this latest wrong site surgery, the state mandated that Rhode Island Hospital take three extraordinary steps, including:
- Installing video and audio recording equipment in all operating rooms;
- Taping all physicians performing surgeries at least twice annually; and,
- Assigning clinical professionals not on the surgical team to monitor operations for one year.
This fine, the highest ever for an episode of wrong site surgery, is a sign that health officials are conscious of the public’s growing intolerance for gross, preventable medical errors. In contrast to Rhode Island, other states and/or courts impose minimal fines on hospitals when medical errors are identified.
For example, the New York Health Department last year fined St. Joseph’s Hospital Health Center in Syracuse $6,000 for replacing a patient’s wrong hip, when an investigation revealed the surgical team did not follow Universal Protocol for WSS.
Florida law holds physicians accountable for WSS. The state will fine physicians a minimum of between $10,000 and $20,000. It will also mandate community service, and require remedial training. If the instance is blatant, the physician’s medical license may be suspended or revoked. This was described by Miami physician, Dr. Allen Livingstone, who noted in a Medscape article that, in 2005, Florida had reports of 31 wrong site surgeries, five patients who were the wrong patients for the surgeries they got, and 86 wrong procedures.
It was 2003 when The Joint Commission introduced the “Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.” The protocol describes a standard routine and acceptable preoperative process of verifying the patient and the correct site, as well as the physician marking the site with his or her initials before the patient is sedated.
Florida, Minnesota, Pennsylvania, New York and Virginia are among the states that require hospitals and/or physicians to report WSS events to state health agencies. However, Pennsylvania is the only state that requires reporting “near misses”—an error caught before the patient was cut by a scalpel.
A report that tracked near misses over 30 months in Pennsylvania makes a strong case for the pause or “time out” protocol to double-check site, side, patient, and procedure prior to cutting the patient. Of 427 WSS events reported in Pennsylvania, 253 events did not touch the patient or were counted as near misses.
The Joint Commission maintains a voluntary reporting policy and receives about eight official reports of WSS monthly. However, its chief patient safety officer estimates the actual number of WSS events is 10 times greater. A report from the Joint Commission Center for Transforming Healthcare says that some estimates place the number of WSS events to be more than 40 times per week in the United States.
The other side of the medical error problem is whether patients are ever told of the error in their care. A national survey of hospital disclosure practices published in the journal Health Affairs, indicates that hospitals and doctors often do not disclose medical errors to patients or agencies, unless required by law to do so. The study noted that epidemiologic estimates of iatrogenic injury rates indicate 44 to 66 such injuries per 10,000 admissions.
Interestingly, just two hospitals out of 245 involved in this study reported disclosures rates in this range. “Our study suggests that there is still a long way to go before serious harm is consistently and thoroughly disclosed to patients,” observed the authors of the study.