Nearly 200,000 people die in Colorado and the rest of the U.S. each year because of a fatal medical mistake. Technology may be able to change the underlying culture preventing clinicians from pointing out errors they witness in a situation such as a surgery. Although it's commonly believed by people in healthcare positions that the cultural fear of punishment hinders technological safety advances, technology could help the culture change to improve efficiency and safety.
Colorado patients may not imagine themselves facing the consequences of wrong-site surgical procedures, but statistics based on certain types of surgeries may cause some to think twice. Reports indicate that for orthopedic surgeons exceeding 25 years of experience, at least 25 percent have been involved in wrong-site errors. Of hand surgeons, 20 percent may perform wrong-site surgeries during their careers. In fact, statistics indicate that a WSS may occur in as many as one of every 112,994 surgical procedures. Unfortunately, the statistics can vary dramatically based on the type of procedure, but with more transparency in reporting, the number of incidents recorded has definitely risen.
Recently obtained documents show that in July 2010, the state of Colorado sanctioned the entire management team at Porter Adventist Hospital, and the hospital was also threatened with the cutoff of Medicare funding. The sanctions were based on the hospital's alleged part in mishandled robot surgeries and other "never events" that included leaving sponges inside patients.The surgical errors are a shared responsibility between the doctor and the hospital. However, the health department does not supervise doctors, but the hospital's actions are subject to federal and state review. Porter Adventist has reportedly created a plan to correct the deficiencies, and in late 2010, the state said the hospital was no longer in danger of losing its Medicare funding.
What most Denver oral surgeons consider a standard procedure turned deadly for a 24-year-old man after he experienced complications during surgery to remove his wisdom teeth. Now his family and friends are questioning whether his surgeon made a surgical error.The oral surgeon says that the patient started coughing and woke up during the removal of his wisdom teeth. He was given propofol, a powerful anesthetic. He stopped breathing, and CPR was started while the staff waited for the paramedics to arrive.
The careless attitude of some surgical teams leads to dire consequences for Denver hospital patients and others throughout the country. According to a recent report, sponges, instruments, needles and other items are left inside patients about 12 times per day across the country. Most healthcare professionals attribute these common surgical errors to human carelessness, but they also agree that there are ways to prevent such problems from happening.Some hospital surgical teams hold everyone on the team responsible for accounting for all instruments used in surgeries. Others claim that mistakes simply happen because surgical teams are made up of humans. However, many surgical professionals as well as patients feel that doctors and nurses should be held to a standard of perfection, particularly when there are ways to prevent errors such as items left behind in patients after surgery.
If facing an upcoming surgery, whether it's a major operation or a routine outpatient procedure, Denver residents may be feeling many different emotions. Many may be looking forward to ridding themselves of a painful medical condition. Others may fear that their condition will not improve, and some may be concerned about the possibility of a surgery mistake. A recent bill passed in Oregon, which mirrors programs in Michigan and Illinois, aims to help those who have been victims of a careless surgeon or other medical errors by giving them options to settle a potential lawsuit prior to going to court. Oregon's State Bill 483-A will allow victims of malpractice and healthcare providers to meet in a confidential setting to discuss the lawsuit, possibly reducing the number of litigation cases throughout the state.
Hospitals are showing less tolerance for doctors who get angry with hospital staff and patients. In the past, administrators have shrugged off bad behavior as simply a by-product of too much stress and too little sleep. However, there are a growing number of patient deaths and surgical errors that cost hospitals money. Known as the Joint Commission, the group that accredits hospitals has recommended zero tolerance for bad behavior from physicians. One surgeon flew into a rage in the operating room when an instrument was loaded incorrectly. The surgeon slammed the instrument down and broke a surgical technician's finger. After the incident, the surgeon was referred to a course in anger management. In another case, the patient was put at risk. An ICU nurse felt the patient was aspirating, which means food or vomit is being inhaled into the lungs, and called the doctor. Not only did the doctor refuse to act; he also verbally abused the nurse. The patient had in fact aspirated, aspiration pneumonia developed and the patient died.
An article titled "To Err Is Human" published in 1999 detailed errors by doctors during surgery and triggered many reforms in the health care field. However, despite reforms of oversights, approximately 4,000 "never events" continue to occur in U.S. hospitals throughout the nation each year, including Colorado."Never events" are major surgical errors. They include leaving surgical items in patients such as sponges, operating on the incorrect site or performing surgery on the incorrect patient. While these events are rare, they can cause permanent damage to patients, and the cost of settlements is a huge financial burden. Some experts suggest that if protocols and checklists are followed in the operating room, the rate of "never events" could be reduced to nearly zero.
There are approximately 50 million surgeries performed in the United States each year. Denver readers might find a recent study of medical malpractice claims rather interesting in that researchers discovered that there were about 10,000 cases of what are commonly referred to as "never events" over a ten year period. Never events include instruments or sponges being left in the patient, wrong site surgery and even surgery done on the wrong patient.
Surgical "never events" encompass incorrectly operating on the wrong patient, conducting the wrong procedure on the correct patient, performing wrong-site surgery, improper organ transplant or leaving surgical equipment inside the patient such as operating tools or sponges, and they cost healthcare facilities billions of dollars in the form of surgery malpractice claims. These surgical errors or mistakes, performed by careless surgeons or negligent operating staff and their improper use of surgical equipment, may result in serious injury or even death. Research results from 1990 to 2010 estimated that malpractice costs paid out to patients reached $1.3 billion; the research results were provided by the National Practitioner Data Bank (NPDB), a federal reserve of medical malpractice claims. An estimated 96 percent of claims were settled and never went to court, but findings show higher compensation was paid to patients who proceeded to trial, sometimes tripling the amount of payment with court settlements. Over 4,000 yearly claims were estimated in the research time frame for surgical "never event" mishaps.