Doctor Gives Public Mea Culpa After Surgical Mistake


In 2004 the Joint Commission, a non-profit that accredits health care organizations and programs, created the Universal Protocol, a global checklist with safety guidelines including a sign-in, recognition of the surgery site, and a time-out to be done before, during and after an operation. The procedures have proven to lower surgical mistakes significantly and save money.

Dr. Atul Gawande, a general and endocrine surgeon at Brigham and Women's Hospital in Boston and director of the World Health Organization's Global Patient Safety Challenge, helped create the WHO "Safe Surgery Saves Lives" Checklist, which includes procedural safety questions before the patient is given anesthesia, before the first skin incision, and before the patient leaves the operating room. In a study published in the New England Journal of Medicine in January 2009, the safety guidelines proved to reduce complications, surgical errors, and death associated with surgery procedures by more than 30 percent.

Surgical Errors Appear to Be Rising

But in a study published in October in the Archives of Surgery, Denver researchers analyzed 27,370 physician-reported adverse events from the Colorado Physician Insurance Co. database and found that Colorado doctors operated on the wrong body part 107 times and performed surgery on the wrong person 25 different times. Twenty percent of the wrong-patient procedures and 38 percent of wrong-site surgeries caused significant harm to patients. One patient died after the doctor operated on the wrong body part. And the number of occurrences went up from 2002 to 2007.

"I was shocked when I saw the numbers," said Dr. Philip Stahel, lead author of the study and director of orthopedic surgery at the Denver Health Medical Center. "I'm not sure if the number of mistakes went up or the reporting of the mistakes went up. Increased vigilance could meet increased reporting."

Preventative Measures Cannot Stop All Medical Errors

Despite safeguards in hundreds of different hospitals, major mistakes still happen. And doctors say the errors are likely to be underrepresented and underreported.

"Just like aviation, we want plane crashes reduced to zero," said Stahel. "This is like a jumbo jet crashing once a week. There should be zero tolerance to these complications."

For three years, Edie Bickoff watched her longtime boyfriend, Richard Flagg, suffer with a lung tumor. On Sept. 5, 2000, Flagg had been admitted to a New Jersey hospital to have the benign mass removed from his left lung. According to Bickoff, Flagg had hoped to get back to work as an oil barge captain soon after the surgery was over.

That was before the surgeon at the hospital operated on the wrong lung. Bickoff said the doctor removed nearly half of Flagg's healthy right lung. By the time doctors had realized the mistake, she said, Flagg had lost so much of his healthy organ that removing the tumor and surrounding tissue from unhealthy left lung was no longer an option. The tumor burst three years after the botched surgery, and Flagg died at age 63.

"I'm not at peace because I lost the love of my life," said Bickoff, a 61-year-old resident of Milford, Pa. "When you see someone treated the way he was treated with such ghastly consequences, it's just awful."

But while no patient wants to be the one to have the wrong foot amputated or have a sponge left in their body, some physicians said the idea of this zero tolerance is simply impossible.

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