Despite the institution of the Universal Protocol by the Joint Committee, which were designed to prevent wrong-site and wrong-patient surgeries, these errors are still taking place, according to a new study.

The Universal Protocol requires a preoperative verification, marking of the surgical site, and a “time out” immediately before the surgery. These requirements were designed to help prevent wrong-site and wrong-patient errors.

The new study, published in the Archives of Surgery, analyzed an insurance database of 6,000 physicians in Colorado to determine the frequency and severity of these errors. Researchers found that between 2002 and 2008, there were 27,370 self-reported adverse events. Of those, 25 procedures took place on the wrong patient, and 107 were wrong-site procedures. Five of the patients experienced significant harm from the wrong-patient procedures, and 38 were damaged by the wrong-site procedures. One patient died due to a wrong-site procedure.

Researchers determined that the main causes of the wrong-patient procedures were errors in diagnosis (56%) and communication errors (100%). The primary root causes of the wrong-site procedures were errors in judgment (85%) and failure to perform a “time out” prior to surgery (72%).


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Additionally, the study found that “nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.”  Twenty-four percent of the wrong-patient errors involved an internal medicine specialist, and 8% involved general practitioners, or doctors specializing in pathology, urology, obstetrics-gynecology and pediatrics. The researchers concluded that “inadequate planning of procedures and the lack of adherence to the time-out concept are the major determinants of adverse outcome. On the basis of these findings, a strict adherence to the Universal Protocol must be expanded to non-surgical specialties to achieve a zero-tolerance philosophy for these preventable incidents.”