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Wrong Side Surgery Doctors Remove Healthy Kidney By MistakeWCCO TV Minneapolis / St, Paul 3/18/2008 A major Twin Cities Hospital admitted to a tragic medical error Monday when doctors removed the wrong kidney. The error happened last week when surgeons were supposed to take out a patient's kidney because it had a tumor believed to be cancerous. By mistake, the healthy kidney was removed instead. Report: OC Hospital Operated On Patient's Wrong Knee Incident Comparable To Others That Have Occurred Since 2006 knbc.com 3/5/2007 ORANGE, Calif. -- For the third time in 14 months, a patient at St. Joseph Hospital in the city of Orange has had the wrong side of the body operated on, The Los Angeles Times reported Saturday. A person with a bum left knee got an operation that was "inadvertently performed on the right knee" on Feb. 15, the hospital disclosed to The Los Angeles Times in an e-mail, the newspaper reported. "No patient should have to go through this," said hospital chief medical officer Dr. Raymond Casciari. "There is no room for error when it comes to patient care. One case is too many," he told the newspaper. State investigators are probing the wrong knee surgery, which comes within a little more than a year of two cases in which patients had medical procedures done on the wrong side of their heads at St. Joseph. R.I. Hospital Cited for Wrong-site Surgery The Providence Journal Friday, August 3, 2007 The Health Department yesterday ordered Rhode Island Hospital to hire a consultant and double-check surgical sites after a neurosurgeon operated on the wrong side of a patient’s head on Monday — the second wrong-site procedure this year at the hospital, and the third in six years. . . . Health Director David R. Gifford said the order against the hospital — called an “immediate compliance order” — is the first such order that his staff can recall ever issuing against a hospital. It indicates that the problem was serious enough to require immediate action even before a full investigation can be completed.. Gifford said he issued the order because of the “pattern” of wrong-site surgeries, all involving neurosurgery at Rhode Island Hospital. In addition to Monday’s surgery, wrong-site neurosurgery procedures were performed in January 2007 and in December 2001. In both cases the hospital pledged to conduct training and improve procedures. Health Director Gifford urged people anticipating surgery to review surgery plans and consent forms with surgeons ahead of time, and to follow the tips for patients at the Joint Commission’s Web site: www.jointcommission.org/PatientSafety/UniversalProtocol/wss.tips.htm Wrong-site Surgery Case Leads to Probe2d Case of Error at R.I. Hospital this Year Boston Globe August 4, 2007 As Rhode Island health officials investigate why a neurosurgeon operated on the wrong side of a patient's skull at a Providence hospital Monday, the national group that accredits hospitals said it is reviewing the adequacy of its guidelines intended to prevent such mistakes. The error at Rhode Island Hospital was the second time this year a neurosurgeon there performed a procedure on the wrong side of the head, and the third such mix-up since 2001. Make No Mistake: Surgery Patients Need to Be Proactive The Providence Journal-Bulletin (Providence, RI) January 27, 2002, Health & Fitness; Pg. N-01 Since 1998 - three years after the problem became nationally known and a focus of patient safety initiatives Doctors Face Sharp Penalty for Wrong Cut The Palm Beach Post July 24, 2001; pg. 1A Doctor fined $10,000 last month by the state Board of Medicine for mixing up two patients. He performed a procedure on each one that should have been done on the other. Errors detailed in kidney removalBoston Globe June 1, 1996, Saturday, METRO Pg. 1 A surgeon at Quincy Hospital who removed the wrong kidney failed to check X-rays that would have revealed the error. Neurosurgeon Suspended after Wrong Side Brain SurgeryThe Washington Post; July 25, 1995; PAge Z05 The chief of neurosurgery at a famous New York hospital has been suspended from his duties after he operated on the wrong side of a patient's brain for a malignant tumor. The patient, has been left with severely impaired vision and no awareness of her left side. A recent report in U.S. News & World Report ranked the hospital as the top cancer center in this country. Hospital Told to Halt Surgeries after Amputation of Wrong FootNew York Times. April 8, 1995, Saturday, Section 1; Page 7; Column 2 Florida State Regulators ordered a hospital here where doctors amputated the wrong foot of a diabetic man in February to suspend elective surgery. In issuing the ruling, the Florida Agency for Health Care Administration noted a series of mistakes in the last three months, including the amputation, the death of a man who was mistakenly taken off a ventilator and an arthroscopic surgery on the wrong knee. Wrong procedure A 67-year-old woman mistakenly underwent an invasive cardiac electrophysiology study.Ann Intern Med 2002 Jun 4;136(11):826-33 Chassin MR, Becher EC. Among all types of medical errors, cases in which the wrong
patient undergoes an invasive procedure are sufficiently distressing to
warrant special attention. Nevertheless, institutions underreport such
procedures, and the medical literature contains no discussions about
them. This article examines the case of a patient who was mistakenly taken
for another patient's invasive electrophysiology procedure. After reviewing
the case and the results of the institution's The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams. Medication Errors OVERVIEW: To Err Is Human: Building a Safer Health System (2000)It has been estimated that for every dollar spent on ambulatory medications, another dollar is spent to treat new health problems caused by the medication. One estimate places the annual national health care cost of drug-related morbidity and mortality in the ambulatory setting as high as $76.6 billion in 1994.98 One recent study conducted at two prestigious teaching hospitals found that almost two percent of admissions experienced a preventable adverse drug event, resulting in an average increased length of stay of 4.6 days and an average increased hospital cost of nearly $4,700 per admission.103 This amounts to about $2.8 million annually for a 700-bed teaching hospital, and if these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole. A study of all patients admitted to a large teaching hospital found that adverse drug events complicated 2.43 admissions per 100.104. The occurrence of an ADE was associated with an increased length of stay of 1.91 days and an increased cost of $2,262. The increased risk of death among patients experiencing an adverse drug event was 1.88. The Costs of Adverse Drug Events in HospitalizedPatients. In review of 4108 admissions to a teaching hospital, 60 patients experienced a serious preventable ADE. Estimated costs attributable to preventable ADE's were $4685 pere event. For a 700-bed teaching hospital, the projected annual cost for preventable ADEs was $2.8 million. A Lesson from Ben; Ben Kolb dies after being given the wrong medication during a routine ear surgeryNBC News Transcripts, Dateline NBC (10:00 PM ET) January 1, 2002 Seven year old dies when he receives epinephrine injection instead of lidcocaine. 10 Common Prescribing ErrorsConsultant 41(6) p. 766 May 1, 2001 Sound-alike Drugs; Lack of Drug Knowledge; Dose Calculation Errors; Decimal Point Misplacement; Wrong Dosage Form; Wrong Frequency; Use of Abbreviations; Drug Interactions; Renal Insufficiency; Incomplete Patient History Hospital Says Two Died in Nitrous Oxide MistakeNew York Times, January 17, 2002; Section B; Page 1 Two women at a hospital in New Haven died in one over the last week after getting nitrous oxide instead of oxygen Medical-Errors Issue Got High Profile PushThe Boston Globe,December 13, 1999, NATIONAL; Pg. A1 Dissussing death of 39-year-old Boston Globe health columnist died following a massive chemotherapy along with other high profile malopractice cases. Lab errors Hospital Admits Fatal Lab Errors; Incorrect Drug Doses Blamed for Deaths of 2 MenThe Washington Post, August 19, 2001, A SECTION; Pg. A02 932 patients given incorrect Coumadin doses due to erroneous laboratory tests . Med mal reform is bad medicineBusiness Insurance, February 24, 2003
Linda McDougal, the Wisconsin woman whose doctor mistakenly performed a double mastectomy on her even though she was cancer-free , has decided to become the poster child against medical malpractice tort reform. At the risk of sounding like a liberal, I'm with her. The tort system's fundamental moral purpose is to punish those who harm others, and, where feasible, to force them to pay restitution to their victims. Capping doctors' malpractice liability for noneconomic damages at $250,000-which is less than one year's salary for most of them-effectively removes the deterrent the tort system is meant to create. Other Errors Porous Safety Net Allows Lethal Medical MistakesUSA TODAY, October 11, 2000, Pg. 1A An overworked nurse infuses the wrong type of blood into a patient. An experienced pharmacist puts the wrong drug in a child's medicine bottle. A less experienced surgeon blows a heart procedure that is performed more frequently, and flawlessly, down the street. Determining Negligence an Inexact Science in Pennsylvania Malpractice CasesCentre Daily Times; January 14, 2001
New Engl. J Med May 16, 2002 Repiratory therapist infects 26 patients by drawing narcotic from intravenous lines. Unexpected hypoglycemia in a critically ill patient (Insulin given instead of Heparin)Ann Intern Med 2002 Jul 16;137(2):110-6 Administration of the wrong medication is a serious and understudied problem. At approximately 8:15 a.m., Ms. Grant's (a pseudonym) ICU nurse heard coughing, entered her room, and found her moving her head and extremities in an uncontrolled manner. The nurse administered labetalol because the patient's systolic blood pressure was greater than 200 mm Hg. The ICU team arrived almost immediately, diagnosed a generalized seizure, administered intravenous lorazepam followed by midazolam, and emergently intubated the patient for airway protection. Serum electrolyte and arterial blood gas levels were measured, and computed tomography (CT) was done to rule out intracranial hemorrhage. Approximately 30 minutes after initiation of these diagnostic and therapeutic maneuvers, the laboratory notified the ICU team that the patient's serum glucose level was undetectable. At 9:15 a.m., a nearly empty 10-mL vial of regular human insulin (100 U/mL) was found on the medication cart outside the patient's room. This finding, in conjunction with the persistent hypoglycemia despite aggressive glucose replacement, suggested that the patient's sudden deterioration had resulted from inadvertent administration of insulin. ABO Blood typing mismatch: A report of 104 transfusion errors in New York State.Transfusion. 1992 Sep;32(7):601-6. Of 104 incident reports in the 22 month study period, there were 54 ABO-incompatible transfusions. Donor Mix-Up Leaves Girl, 17, Fighting for LifeNew York Times, February 19, 2003 Section A; Page 1 Jesica Santillan, A 17-year-old girl, is in critical condition after mistakenly being given a heart and lung transplant from a donor with the wrong blood type at Duke University Hospital in Durham, N.C. The donor had Type A blood, and Ms. Santillan Type O. Suit Says Transplant Error Was Cause in Baby's DeathNew York Times, March 12, 2003; Section A; Page 23 A year-old baby died in August at Children's Medical Center in Dallas after a surgical error destroyed her liver and doctors tried to save her with a transplant but mistakenly gave her a liver of the wrong blood type, according to a lawsuit filed on Monday. The case is the second to come to light in recent months in which a child died after a transplant team failed to take the most basic precaution of making sure an organ donor and recipient had compatible blood types. The Duke case revealed that the most sophisticated medicine at an elite institution could be undone in a moment by a simple human error. In the last 15 years, although thousands of transplants have been done, only about a dozen mismatches have been revealed to the public or reported in medical journals. But the number may be an underestimate. BLOOD ERRORS — Blood Mix-Up Caused DeathNewsday (New York) NASSAU AND SUFFOLK EDITION, May 6, 2002, Pg. A06 Twice within six days during April 2000, the lawsuit says, Ying Lung Chiu Wong of Chinatown was transfused with the wrong type of red blood cells and plasma. Shortly after the second incorrect transfusion, Wong died. A Newsday investigation, published last month, found that between 1995 and 2001, 441 hospital patients died following transfusions, including 78 who received the wrong blood. The state-of-the-art computer was programmed to prevent mistakesThe Boston Globe, December 11, 2000, METRO Pg. A1 The machine beeped again and beamed a more urgent message: |
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