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Three Shocking Medical Mistakes – And Why They Happen

For many years, the most widely quoted estimate of the number of patient deaths caused by medical errors each year in the U.S. came from a 1999 report issued by the Institute of Medicine (IOM), “To Err is Human.”  That number: 98,000. However, the IOM study used 1984 data.

In 2013, researchers published a study in the Journal of Patient Safety that sought to provide a more up-to-date estimate of the number of preventable patient deaths in the U.S. They reviewed four studies published between 2008 and 2011. Unfortunately, the researchers arrived at a much higher number than the IOM.

According to the study, more than 400,000 patients die each year in U.S. hospitals and clinics due to preventable medical errors.

As ProPublica noted at that time, based on the figures from the Centers for Disease Control and Prevention (CDC), this would make preventable medical errors one of the leading causes of death in the U.S., ranking just behind heart disease and cancer.

Leading Causes of Death in United States

Based on Journal of Patient Safety figure and CDC statistics

As the researchers behind the 2013 study wrote:

“[O]ne must hope that the present, evidence-based estimate of 400,000+ deaths per year will foster an outcry for overdue changes and increased vigilance in medical care to address the problem of harm to patients who come to a hospital seeking only to be healed.”

Among the many changes that the researchers called for was a greater emphasis in the medical community on “intentional correction of root causes of harm.”

Along those lines, a new study published in June 2015 in JAMA Surgery sheds light on the root causes – and the approaches being taken to correct those causes – on three specific – and shocking – medical mistakes: Wrong-site surgeries, retained surgical items and surgical fires. These are commonly referred to as a “never events” – meaning, of course, they should never happen in modern medical facilities. Let’s take a closer look at what the study found.

Wrong-Site Surgeries

The researchers, who reviewed 138 empirical studies, placed several different types of surgical errors into the category of wrong-site surgeries, including:

  • Operating on the wrong site or wrong side of a patient’s body
  • Performing the wrong surgical procedure
  • Inserting the wrong implant
  • Operating on the wrong patient.

The study found that these wrong-site surgeries occur in the U.S. at a rate of:

  • 1 event per every 100,000 surgical procedures, or
  • 500 wrong-site surgeries per year.

According to the study, the leading root cause of wrong-site surgeries is communication problems. For instance, miscommunication can occur among staff members in the operating room, or important information about a patient may not be given to operating staff. In some cases, members of the surgical team may be too afraid to speak up when they see a surgeon operating on the wrong site.

Retained Surgical Items

As the researchers found, the surgical item most often left behind in a patient’s body is a surgical sponge. The sponge typically is used to soak up and clear away blood during the course of an operation. Numerous sponges can be used. However, other items can be left behind as well, including surgical instruments.

The study found that retained surgical items occur in the U.S. at a rate of:

  • 1 event per every 10,000 surgical procedures, or
  • 5,000 retained surgical item incidents per year.

As with wrong-site surgeries, the researchers identified communication breakdowns as a leading cause of this serious medical mistake, which can cause patients to suffer infections and a host of other complications.

Additionally, the study found that surgical items can be left behind due to a failure to document or count how many items are used and a failure to follow hospital policies that mandate counting or use of technology to track items.

Surgical Fires

The study could not arrive at an estimate of how many surgical fires occur annually in U.S. medical facilities. However, the researchers did identify some common characteristics of these fires, including:

  • Electrocautery (use of a heated tool) was a common ignition source
  • Endotracheal tubes, drapes and towels were common fuel sources
  • Neck and facial surgeries had the highest risk of surgical fires.

The researchers found many fires are caused by “lack of staff awareness of – and failure to communicate – risks.”

What Can Be Done to Prevent these Medical Errors?

As you can see, poor communication is a common cause of all three of these serious medical errors. It follows that hospitals should focus on improving communication procedures in order to reduce and – ultimately – eliminate these mistakes.

A standardized reporting system for medical errors could also help to analyze and remedy problems, the researchers found. In other words, members of the medical community have to communicate with each other to determine what is causing these serious errors and to learn about effective strategies that are being followed to prevent them.

If you or a loved one has been harmed due to a wrong-site surgery, retained surgical item or surgical fire, you should contact a lawyer immediately. At Davis, Saperstein & Salomon, P.C., we can investigate your case and help you to seek compensation for the harm you have suffered. Simply call or reach us online.