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Running head: Risk management Name: University: Lecturer: Date: Wrong-site surgery at St. Joseph's Hospital Health Center Outline of content Content Page Abstract 3 Introduction 3 Wrong-site surgery incidence 3 Implications of the wrong-site surgery to the patient 4 Implications of the wrong-site surgery to the hospital 4 Causes of wrong-site surgery 5 Process of investigating a wrong-site surgery 5 Reducing the risk of wrong-site surgery 7 Conclusion 7 References 8 Abstract Medication errors are but one unfortunate facet of reality spawned by the advance of medicine. While fundamentally traumatic, there is consolation in the fact that they are, by definition, preventable. This paper concentrates on one particular type of medication error: wrong-site surgery. It narrates the occurrence of such a surgery, and the consequences that followed.
It also delves into the mechanisms of investigating such incidences, and how to prevent them from happening in future. Introduction In risk management, processes that would otherwise cause untoward losses are analyzed with the aim of reducing or eliminating the losses. In medicine, this practice is especially useful in doctor-patient relationship, whereby an open communication channel helps keep both parties updated about development, as far as the ailment or injury is concerned. Sometimes, however, medication errors do occur, and have to then be dealt with in a control rather than a preventative mode. Medication errors are any adverse events that could, with present knowhow and capabilities, be avoided. They can occur if a planned action fails to be completed according to plan, or if the plan in place for achieving a certain goal turns out to be wrong.
They can arise from flawed procedures or practices, or from using the wrong products (Surgery, 2007). Wrong-site surgery incidence In July, 2007, a patient in St. Joseph's Hospital Health Center, Syracuse, was mistakenly operated on the left hip. The patients right hip was fractured, and somewhere between diagnosis and the surgery room, the medical staff within the hospital got the two hips mixed up. The patient ended up with multiple screws fixed into his left hip. While in the recovery room afterwards, the mistake was discovered.
The medical staff once again operated on the patient and put the screws into the right hip. For their mistake, the State charged them $ 6, 000. The case had by then escalated to gain the attention of the Health Department. The patient also decided to sue the hospital for the malpractice, and this reduced the amount of information available for public scrutiny (James, 2008).
Implications of the wrong-site surgery to the patient The implications from this never event are extensive in scope. Both the patient and the hospital came off the worse for it. The patient had to contend with a recovery on both sides of the hips, since both sides would thereafter need medical attention. There was the possibility of the previously healthy left hip developing complications, or at least weakening from the screws that had been inserted. Regardless of the medical interventions afforded to the patient thereafter, this unfortunate event would always have an effect on his confidence in hospitals and all medical staff.
Family members and close friends to the patient would also perceive that particular hospital in a different light. At the very least, these people are likely to avoid that hospital whenever possible. Implications of the wrong-site surgery to the hospital St. Joseph's Hospital Health Center, on the other hand, stood to lose a lot in terms of public reputation.
The fact that even a small amount of information about this unfortunate incidence leaked to the public is enough to destroy a reputation built over years. Due to the costly consequences, the particular medical staffs directly linked to this mistake were likely to either be fired or have their practicing licenses suspended. The legal suits could drag the hospital through several weeks or even months of negative public scrutiny, further damaging its image to the public eye. Additional investigations could be initiated in the hospital to try and identify similar cases of negligence. Ultimately, the hospital would have been set back several years in its popularity status. Causes of wrong-site surgery According to the Joint Commission Accreditation (JCAHU), the incidences of wrong site surgery are, quite surprisingly, increasing.
The reasons for this increase are many, and on most cases, several factors gang up together to lead to such incidences. For example, if several surgeons are involved in the operation, confusion may arise, whereby the surgeon who finally performs the surgery isnt the same one who diagnosed the ailment. Some patients also require multiple operations on different parts of the body, and this could also lead to confusion in the operating room. If the surgeons performing the operation are harried or under any kind of time pressures, they may end up making more mistakes. And finally, the patient may be having some physical deformities or unusual characteristics such as obesity which may lead to a different configuration of the operating equipment and placement of instruments, leading up to more confusion (Joint commission, 1998). Process of investigating a wrong-site surgery When performing a background investigation to this kind of an event, several crucial facts need to be ascertained.
The exact flow of events relating to the flawed operation should be recorded. This can be done by getting written statements from the patient, and the hospital staff, and ensuring that the two corroborate on the main aspects. The patients medical history should be recorded and ascertained by checking all previous check-ins with that particular hospital. In this case, all correspondence between St. Johns Hospital Health Center and the patient should be scrutinized. The reason for this exercise is to remove any bias from the recorded story line, and thus ensure that the recorded flow of events is objective and comprehensive (Saufl, 2004).
The risk management team thereafter needs to check the hospitals background. Are there similar cases on record? Who are the personnel involved? Is there is common link between all such cases and the personnel involved? Is the incompetence a result of low personal qualifications, or are there extenuating circumstances in the hospital? For example, is the medical staff working under extreme pressure?
Is the hospital understaffed? What exactly happened when the hip surgery went wrong? All these queries need concrete answers, if a good risk management program is to be created. The reason for the hospitals background check is to expose any single persons or chain of event around whom or which the chances of a wrong-site surgery increase. For example, in St. Johns Hospital, wrong-site surgery had been reported severally before.
In 2006, at least three such wrong-site surgeries occurred. All of them had relatively minor consequences once they were rectified, but their very occurrence in the first place is justifiable cause for alarm (Mary, 2008). As already implied, wrong-site surgeries are ideally non-events, meaning that they shouldnt occur ever. Any one single incidence is simply one too many. Any exposes the patient to anything from mild complication to the possibility of death.
If there is a person in the hospital who is simply reckless, then he or she should be brought to justice. After the flow of events for the incidence has been ascertained, steps should be taken to rectify any wrongs done. The patient should be compensated for the inconvenience caused. It is important to note that no compensation is ever adequate for wrong-site surgeries. What the hospital and the staff can do is provide a token of consolation, and thereby show their willingness to work towards better hospital standards. Any retribution from the patient should also be dealt with diplomatically, for the patient has every right to be upset with the hospital.
After all, it is his or her own body and health on the line. Reducing the risk of wrong-site surgery The risk of similar events happening in future can be reduced by following several avenues. For one, the patient should be actively involved through verbal communications, as a means of ascertaining identity and relevance of the operation. Incredible as it may seem, sometimes surgeries are done on the wrong person when the patients input is ignored. The operating site should also be clearly marked using indelible, FDA approved skin ink. This will prevent the low, but significant, risk of operating on the other side of the body operating on the left foot instead of the right one, for example.
A verification check list should also be developed. This list contains all documents and data relevant to the operation procedure like the x-ray, medical records, informed consent record and so on (Joint commission, 1998). Put together, these items serve as additional guarantees that no surprises will arise from the operation. Conclusion Medication errors take many forms, and range in scope from in terms of the consequences. Wrong-site surgeries, though ideally non-existent, do occur in reality, every now and then. Their consequences range from mild to life threatening.
There are many cases of patients loosing their lives under the surgeons knife. Others have had their lives radically altered for the worse due to these mistakes. Therefore, any effort to eradicate wrong-site surgeries, together with any other kind of medication error, is justified. References James T. Mulder (2008) St. Joes fined in wrong-site surgery 18 th April 2009 < web > Joint Commission (1998) Lessons learned: wrong site surgery 18 th April 2009 < web > Mary Engel (2008) Orange hospital under investigation for operating room error 18 th April 2009 < web > Saufl NM Universal protocol for preventing wrong site, wrong procedure, wrong person surgery J Perianesth Nurs 2004 Surgery Encyclopedia (2007) Medical Errors 18 th April 2009 < web >
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