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Since 1998, the number of operations performed
on the wrong body site or the wrong patient has increased
dramatically.
The JCAHO is an independent commission
that evaluates and accredits about 18,000 healthcare organizations
and programs in the US.
In 1998, the JCAHO issued a Sentinel
Event Alert after 15 "wrong site" surgery cases
were reported to it. By the time the current report was released,
this number had skyrocketed
to 150.
According to the new figures, orthopaedic/podiatric
operations were the most common procedures linked to errors,
accounting for 41% of the 126 cases that were analyzed.
General surgery procedures accounted for
20% of the cases, neurosurgery operations for 14%, and urologic
surgery operations for 11%. The remaining cases involved other
procedures such as dental/oral operations.
Fifty-eight percent of cases occurred
in an outpatient surgical setting, 29% in an inpatient operating
room, and 13% in other inpatient settings. Most of the errors
involved operations on wrong body parts or sites, but 13%
involved operations on the wrong patient and 11%
involved the wrong surgical procedure.
The JCAHO also identified a number of
factors that seemed to increase the risk of surgical mistakes.
Among these, emergency cases and physical characteristics
of the patient -- such as morbid obesity or physical deformity
-- were the most commonly cited.
In addition, most cases involved a "breakdown
in communication" between surgical team members and the
patient or the patient's family.
The JCAHO is also offering some advice
to patients on avoiding surgical errors:
- Make sure you and the surgeon agree
on exactly what will be done during the procedure.
- Ask to have the surgical site marked
with a permanent marker and to be involved in marking the
site.
- Ask questions and speak up about any
concerns.
Have the surgery at a JCAHO-accredited
facility. Consumers can find out if a facility is accredited
by going to the commission's Web site: www.jcaho.org.
Report
by the Joint Commission on Accreditation of Healthcare Organizations
December 4, 2001
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