Medical Mistakes Caused by Combo Errors

NEW YORK-Two doctors in New York states last year were accused of operating on the wrong side of a patient's brain and still a third was found guilty of performing surgery on the wrong section of a spinal cord.

Another doctor lost his license for removing the left kidney of an elderly patient who had a cancerous mass on his right kidney. A different doctor performed surgery on a healthy knee, rather than the injured one. He had made the same mistake five years earlier.

A new study from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has found that the surgeon in each of these cases is not solely to blame. Medical errors stem from a series of small, crucial mistakes of those who deal with the patient, flaws in the hospital's operating procedures, and the culture of American medicine.

Often human and systems errors combine causing problems. If an X-ray is incorrectly reversed when placed on the light box, a tumor may appear on the right lung, when in truth, it is on the left. It is both the surgeon's and the technicians responsibility to double check this information. The X-ray should also be manufactured with a large L or R to prevent this from happening.

There are two categories that lead to wrong-site surgery. Latent conditions are caused by the way a staff communicates during an operation. A set number of people should verify that a correct limb and the correct patient are being prepared for surgery.

Environmental conditions include staff shortages and subspecilization. These are more difficult to fix.

A recent study in the British Medical Journal compared the workplaces of airline pilots and surgeons. Both groups often deal with younger, less experienced people working next to them. Both groups also said they do not appreciate being second-guessed. Pilot's training was changed in the last few years to change this attitude. Airlines have encouraged teamwork and those who are inexperienced are encouraged to speak up when they see a problem.

Surgeons, on the other hand, rarely hear their intern's voices. In the study, 45% of surgeons said junior team members should not questions decisions made by senior members.

This attitude may contribute to the estimated 44,000-98,000 medical mistakes that hospitalize Americans each year.

Information from www.nytimes.com