Horror Headline: Operation Mix-Ups on the Rise?
Never events: That’s how medical professionals describe what happened in April 2011, in an Oregon hospital during an eye surgery for three-year-old Jesse Matlock. He went in for a procedure to correct his lazy right eye, but the doctor operated on his left eye first, realized her mistake, and immediately repeated the same procedure on the right. A few weeks post-op, Jessie’s mom reported that the toddler’s left eye was wandering, and the right didn’t seem fixed.
This is the kind of mistake that simply should never happen. But wrong-procedure, wrong-patient, and wrong-site surgeries still occur about 40 times a week, according to recent estimates by a group that accredits U.S. hospitals. In 2004, this same group established a universal protocol to help prevent these errors, requiring pre-op verification, a mark of the surgical site, and a time-out to confirm everything before surgery starts. Yet some experts say the problem of wrong-site surgeries has not improved and may even be getting worse—in part because physicians aren’t following the guidelines.
Horror Headline: Dirty Tools More Common Than You Think
John Harrison checked into Houston’s Methodist Hospital in 2009 for a routine rotator cuff repair. Soon after, the area around the 63-year-old’s scar became bright red and painful. An infection had eaten away part of the bone and loosened screws that surgeons had just placed. Within a short period, at least six other patients at Methodist developed similar infections. The hospital ultimately found an alarming culprit: Human tissue and bone were inside supposedly sterile surgical instruments; bacteria from that leftover matter likely caused the infections. There were other reports in 2009 that more than 10,000 veterans in Florida, Tennessee, and Georgia had procedures with improperly cleaned endoscopes; some of them later tested positive for HIV.
Bad design of equipment and inadequate testing by manufacturers are partly to blame. A researcher from the University of Michigan checked 350 suction tips with a video camera and found that almost all of them had some kind of debris, even after they had been cleaned according to the manufacturers’ instructions. And sterilization workers may not be properly trained. New Jersey is the only state that currently requires technicians to be certified (New York, Ohio, and Pennsylvania are considering legislation requiring certification).