Hospital mistakenly operates on wrong knee

Despite ‘time out’ to check patient details, error still made

By Owen Boss

GARDNER — A Heywood Hospital patient who went under the knife for arthroscopic surgery in June woke up to find that the orthopedic surgeon had operated on the wrong knee, hospital officials have confirmed. “We are deeply sorry that this happened and we are committed to ensuring that it does not occur again,” said hospital President and CEO Daniel P. Moen in an official statement. “The patient is not expected to experience any long-term effects from this error,” he added. According to the same statement, the hospital reported that key members of the medical staff have completed a “root cause analysis” which includes a review of processes and procedures that were in place at the time and an analysis of factors that may have contributed to the error. Although a “time out” was performed, where physicians and staff reviewed important details prior to the surgery, it did not prevent the error. The surgeon, whose identity has not been released, and the hospital apologized to the patient. In accordance with policy, both the hospital and the physician will not be billed for the procedure. An independent, not-for-profit organization called The Joint Commission, which accredits and certifies more than 15,000 health care organizations and programs in the United States, is responsible for listing the incident and making the report available to patients and other hospitals. According to the commission’s Web site, since January 1995 when they originally began listing wrong site surgery — “sentinel” — events, there have been 651 reported wrong-site operations, but that information is based solely on voluntary reports from hospitals, and Ms. Zhani said the actual number could be “much higher.” According to Elizabeth Zhani, spokesperson for The Joint Commission, all accredited hospitals are expected to follow a standard operating procedure to prevent these situations from happening. “What we have is a universal protocol for the prevention of wrong site, wrong patient, and wrong symptom surgery,” said Ms. Zhani. “And all accredited hospitals are expected to be in compliance with this policy.” Although it is ultimately up to the hospital to report the incidents, Ms. Zhani said it is the commission that compiles a list of all errors so that other hospitals can learn from previous mistakes. “We would call a situation like this, with a wrong-site surgery, a sentinel event,” said Ms. Zhani. “Following a sentinel event, our policy is that the hospital perform a (reanalysis) to implement an action plan so that something like that does not occur again. We encourage them to report these incidents to us so other institutions will learn from their situation.” oboss@thegardnernews.com

Appeared on Page 1 on 7/16/2008 (Vol. 206 No. 167)