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Avoiding Surgical Errors

Posted by: Craig A. Knapp
August 31, 2011
Topic: Surgical Errors

Many people suffer from surgical errors every week. Although this number is relatively low when compared with the thousands who have surgery each week, a recent study shows this number could be almost 75% lower when proper measures are taken.

What does "surgical errors" mean?

In this study that took place, the term "surgical error" included not only wrong site surgery, but also wrong side surgery, wrong patient surgery and wrong surgical procedures.

In July 2009, The Joint Commission Center for Transforming Healthcare and the Lifespan system in Rhode Island initiated a project aimed at improving "the safeguards to prevent patients from wrong site, wrong side and wrong patient surgical procedures." They did this by implementing the Robust Process Improvement (RPI), a fact-based, systematic, and data-driven problem-solving methodology.

What did the project entail?

According to their project overview, "Using RPI, the project teams measure the magnitude of the problem (or, in the case of wrong site surgery, specific problems that increase the risk of this event), pinpoint the contributing causes, develop specific solutions that are targeted to each cause, and thoroughly test the solutions in real life situations."

After studying 8 different hospitals, the project found that most surgical errors arose from a collection of small errors rooting from 4 different areas: scheduling, pre-op period in the hospital, operating room, and the medical center's culture.

Below are specific examples of each area:

Scheduling Errors: accuracy of surgical booking documents is not checked and confirmed, verbal requests for surgeries are accepted in replace of written requests, missing required forms at the time the surgery is scheduled, illegible or incomplete information on surgical booking forms

Pre-op Errors: missing or incorrect required medical documents, insufficient or rushed patient verification process; incorrect or improper surgical marking including failing to mark the site of surgery in the pre-op holding area or inconsistent site marking or someone other than the surgeon making the surgical mark, using the wrong kind of marker or a sticker instead of a marker, inconsistent or absent time out process (Time out procedures vary by hospital and state. However, at Arizona's Banner Health, it's a three step process led by the surgeon where all team members participate in the time out with the surgeon by identifying the patient, the procedure to be performed and the site/side of the procedure.)

Operating Room Errors: failure to verify site of surgery between each procedure being performed; failing to participate in time out by verifying the patient, procedure, site and side before beginning surgery; removing site markings or covering them; ineffective use of time out to ensure every member of team understands what's happening and ensuring all concerns have been addressed

Medical Center Cultural Errors: staff isn't empowered to speak, staff is uneducated about current policies, pressure to conduct more surgeries leads to shortcuts and rushing, disregard patient safety

The RBI Project mentioned above went through each of these errors and carried through a solution to each one, which you can find here. In the study, they found that surgical errors are avoidable, and when the solutions they designed were used, surgical errors were reduced by 72-percent. If you or someone you know has suffered from a surgical error, give the experienced attorneys at Knapp & Roberts a call. This study proves that many institutions are not taking proper safety and precautionary measures to ensure your safety during surgery and we can help. Give us a call.


The Knapp & Roberts law firm represents serious injury and wrongful death clients throughout Arizona, including the communities of Phoenix, Scottsdale, Tempe, Chandler, Gilbert, Mesa, Glendale, Peoria, Surprise, Queen Creek, Apache Junction, Goodyear, Tucson, Flagstaff, and Yuma in the Valley of the Sun - Maricopa County, Pinal County, Coconino County, Yuma County, and Gila County.