June 12 is National Time Out Day

I don’t generally read The Annals of Internal Medicine for its gripping narratives, but on June 4, 2002, they have an article intriguingly titled, “The Wrong Patient.

It’s as bad as it sounds.

A 67-year old woman was admitted for a cerebral angiography. And the un-named hospital went along and imaged her veins and arteries, like you do in these situations. The surgeons were even able to successfully embolize one of her aneurysms–and plans for her discharge on the morrow were in the making.

After the completion of the procedure, they took her to … I’m taking open to guesses here… the oncology floor. Of course! It’s true her own bed on her former floor (in the telemetry unit, where she would have been under electronic monitoring, where she belonged after her procedure) was sitting there waiting for her, but let’s not get bogged down in details.

So come the next morning, before she gets a chance to be discharged, they come for her, take her in to the OR, and – this is where it gets really good – run an invasive cardiac electrophysiology study.

Now, that’s bad enough–but this part is even weirder to me: one hour into debacle (and I just couldn’t imagine why. What surgeon wakes up one hour into surgery and says, “hey you think this is the right person?” I mean, what is there to look at 60 minutes into this process that would awaken such a suspicion? [But actually it does become clear if you’re welling to read the minute-by-minute play-by-play in the article. Enjoy the link]), “it became apparent” that this lady was not the right person.


And much as I’d like to say that this type of thing never happens, well, I’d be flat-out lying if I did.

Just as an example, over a 6-and-a-half-year period, Colorado doctors reported 25 wrong-patient procedures to a liability insurance database, Medpage Today found. Researchers crunching the numbers from another state, which they wouldn’t name (probably wisely), found that over the course of 30 months “there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient” (Clarke et al 2007).

Very comforting.

Frankly, operating on the wrong person is probably about as bad as it gets – so maybe I started with a bang and it’s all down-hill from here– BUT. . . I’m pretty shocked and appalled by a number of other goofs that occur in the OR–particularly:

  • the number of surgeries that take place on what they call the “wrong site” (translation: they are supposed to take your right kidney, the cancerous one, but instead they decide to go for the healthy left one), and
  • the number of items that just get ‘left behind’ by surgeons, once there’s a conveniently open body.

Well–everyone seems aware that operating on the wrong person, or removing the wrong limb, or forgetting your scalpel in the abdominal cavity–they’re all pretty bad.



But it took our government (“we’re from the government, we’re here to help you”) to synthesize all three errors and to put a name to the face of this kind of medical practice. As far back as 2001, a Dr. Ken Kizer, MD, of the National Quality Forum, created the phrase “never events,” which applies to certain medical errors that are completely inexcusable and should never occur. Perhaps it does not surprise you that operating on the wrong patients–or the wrong part of the patient–and leaving objects inside patients that really do better outside, all these count as ‘never events‘ (despite the fact that they occur with what is really surprising regularity. You can close your eyes and say ‘never never,’ but you’ve still got surgeons knocking off the wrong digit, performing surgery on the wrong side of the brain, dropping multiple sponges in the human cavity. . .the words alone won’t make it stop.).

But let’s return to my tiny bullet list above for the moment, and focus on the former point, the goofs called ‘wrong-site’ mistakes–like amputating the wrong arm, or taking out the wrong lung, or say, operating on the wrong side of a patient’s brain. That’s just not something you want to have going on, now is it? However, one Regina Turner, as reported by the Huffington Post–on May 3, of this year–went to the hospital for a craniotomy bypass (there are many types of craniotomies, but typically a section of the skull is removed to allow access to the brain underneath).

Scheduled on April 4 for a “left-sided craniotomy bypass,” the 53-year-old female patient instead received. . . .a “right-sided craniotomy surgical procedure.”

And the results were anything but pretty.

The Washington Post shared some high profile-cases from which I plucked a few favorites, and then I found some others, just lying around in the media, to be picked up and shared:

  • In LA, in 2006, a surgeon removed a healthy testicle from a 47-year-old Air Force veteran.
  • In 2010, in Orange County, California, a surgeon operated on the wrong part of a young child’s tongue. Which is truly bad, but things are still worse in. . .
  • Portland, where an ophthalmologist operates on the wrong eye of a 4-year-old boy in 2011.
  • NBCNewYork piped in with a 2007 C-section performed (with a cut through the belly and everything)–on a woman who didn’t happen to be pregnant.
  • And the NewYorkTimes blog shared a trifecta of error with us, when, apparently, surgeons at Rhode Island Hospital operated on the wrong side of a patient’s head–not once, not twice–but three times, in one year (2007).

Sound like freakish events, something out of the mind of a whacked-out science-fiction writer?

Well, it seems like, in fact, they happen with unacceptable regularity. According to a 2006 study looking at the frequency of surgical errors in the United States, each year there could be as many as 2,700 mistakes where a surgery is performed on the wrong body part or patient. That’s about seven per day.

Well, you might say, that was 7 years ago–I’m sure we’ve moved no since then. Okay.

Let’s look at an April 28, 2011, CNN piece which found that–again in the U.S. alone–there could be as many as 2,700 errors, if you include surgeries on both the wrong patient and the wrong body part. They kindly did the math for me–that’s seven per day, which ought to wring a bell.

So, if you do s0me heavy-duty mathematics here, multiply times 7, carry the 1 . . .you’re going to find what Medscape found, that as of 2011, despite improvements and efforts, wrong-site surgery was occurring about—-wait, I don’t want to deprive Medscape of the opportunity to give it all away in their title–“Wrong-Site Surgery Occurs 40 Times a Week.”

So we’ve established that that’s a pretty bad scenario–but let’s return to the latter bullet-point, that getting stuff left inside you after your operation. Apparently that’s a heck of a lot more common than we’d like as well.

Back in 2007, ScienceDaily gave us another of those titles that make further reading extraneous, with “Surgical Objects Accidentally Left Inside About 1,500 Patients In US Each Year.” Pretty clear, but. . .

I wanted to check that number–but this is really a strain for my math skills, so I ask my readers for help. Good old WebMD with the fairly non-committal title, “Thousands of Mistakes Made in Surgery Every Year,” estimated–and in reality it is just an estimate, based on malpractice claims and voluntary hospital reporting– as of the end of 2012, that each and every week, surgeons:

  • Operate on the wrong body site 20 times;
  • Leave a foreign object like a sponge or towel inside a patient’s body after an operation 39 times (and I warn you before you head down to the next bullet–this one’s a shocker:)
  • Perform the wrong procedure on a patient 20 times (remember–a week!).

It all sounded pretty bad–until it got even worse, when I came across probably the ‘winner’ of “Objects Left Behind After Surgery,” if such a contest exists: one Dirk Schroeder, who had an operation for prostate cancer in 2009.

Apparently the surgery went well (although it sounds to me like the surgeons must have been particularly preoccupied picking up objects and dropping them inside poor Mr. Schroeder–it’s fortunate they could operate at all, being thus engaged). They left a whopping (I’m open to guesses here–anyone?)–16, count ’em, 16–items inside his body during the operation. According to the Daily Mail, among the objects Mr. Schroeder temporarily housed were a needle, a six-inch role of bandage , a fragment of surgical mask, a six-inch roll of bandage, and several sponges.

Those last objects are no surprise, since, according to the 2008 Journal of Medical Case Reports, it ishe surgical sponge that is most often left behind. (Wait–I must catch you up on the lingo. These objects are known as Retained Surgical Objects, or RSIs. Now know.) In fact, the sponge makes up two-thirds of all objects left behind. And, although I hate to think of this, if you picture the surgery site, visualizing an open, bloody cavity, with sponges soaking up the blood, you can come to imagine how they might get left behind, just part of a bloody, gloppy mess.

Clearly, it’s a situation that needs help–and needs it fast, since the results of operating on the wrong person, the wrong site, or leaving foreign objects in a body–well, they range from illness and pain to. . .much worse things.

So what’s really good to know, though, after hearing all this, is that the U.S. Department of Health and Human Services is on it.

Truthfully, they’ve been on it for a while, and together with them, we all can make. . .a national awareness day.

No, no, it’s not just that. The government and healthcare groups have worked to make a difference.

1. First–they took matters into their own hands and prioritized what needed to be done first–they’ve created an acronym. So “wrong-site, wrong-procedure, wrong-patient errors,” which really is an unwieldy phrase, if you think about it, got turned into “WSPEs,” and I’m sure everyone felt a lot better about the whole thing.

2. As I’m sure you’ll recall, they didn’t stop there with the linguistic contributions. National Quality Forum declared these very-much-real events ‘Never Events.’ And we thank them.

But. . . NOW what? I mean, creating an acronym and establishing that yanking a wrong finger is a real no-no–that really only takes us so far. What do we do to prevent these ‘never events’?

It was as late as 2003 that the Joint Commission (an independent, non-for profit organization that accredits and certifies thousands of health care programs and organizations in the U.S.) pulled together the leaders of 23 other healthcare organizations in a summit, and finally came out with something–in this case The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.

It’s simple enough, and has three major elements, one of which will take us right up to the purpose of this day.

1. Identification. Everyone involved should check and make sure they’ve got: the right person, the right procedure, and the right site .

2. Surgical site marking. I like this one, as the Commission recommends that surgeons mark “at or near the incision site. Do NOT mark any inoperative sites. . .” If you have artistic ambitions, the place to display them is elsewhere. ONE mark–period.

3. A time-out. You thought I’d never get here, right? So the third part is, as the government’s Department of Health and Human Services helps me define it, “a planned pause before beginning the procedure in order to review important aspects of the procedure with all involved personnel.” The Protocol insists that right before the operation begin, all members of the OR team agree to the information from step # 1.

And the time-out is meant to be a biggie–and for surgeons to know that it is. An issue in the 2007 Annals of Surgery (Michaels) describes the time-out as an “independent check to potentially identify and correct errors. This intentional pause before incision is a communication tool, and final safety check between the surgical, nursing, and anesthesia care teams.”

Enter AORN, or the Association of periOperative Registered Nurses. Quite aware of how important the Universal Protocol is in these cases, they really went to town creating. . .well, stuff, that could help surgeons implement the Protocol.
And to start off with a bang (and to let me end, much to your relief by this point, I’m sure), what they’ve succeeded in creating, beginning in 2004 was:


AORN claims the time-out is “a powerful tool that supports surgical nurses’ ability to speak up for safe practices in the operating room.”
And I say–Bring the time-outs on!
AORN has created a day where, every June 12, we celebrate surgical teams’ taking a step back and verifying important details, like, do we have the right patient? Are we planning the right procedure? Will we be removing the right foodt? The right testicle?
It’s hard to be opposed to a day that encourages this.
So, look, let me be the first to ‘fess right up and admit that this doesn’t have the joy of National Smile Month, or the true festivity of English Wine Week, or the real meaty satisfaction National BBQ Month–but, if you or anyone you’ve ever loved has to go under the knife, it’s a day definitely worth thinking about.

Works Cited

Chassin, M.R. & Becher, E.C. (2002). The wrong patient. Annals of Internal Medicine, 136(11):826-833.

Clarke, J.R., Johnston, J., Finley, E.D. (2007). Getting surgery right. Annals of Surgery. 246(3):395-405.

Malloy, D.F. & Hughes, R.G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 36. Wrong-site surgery: A preventable medical error. Agency for Healthcare Research and Quality. Retrieved from the World Wide Web on May 28, 2013.

Michaels RK, et al. (2007). Achieving the National Quality Forum’s ‘never events’: prevention of wrong site, wrong procedure, and wrong patient operations. Annals of Surgery, 245:526–32.

Rice, R. (April 28, 2011). Patients, beware of wrong-side surgeries. Retrieved from http://edition.cnn.com/2011/HEALTH.

Sutherlin, E. (January 16, 2013). Surgeon leaves 16 medical items in patient’s body after operation. Retrieved from http://www.examiner.com.

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