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Does your surgeon have a Sharpie?

A permanent marker is a patient's best defense against being a victim of a surgical error, a hospital accrediting agency says.

© St. Petersburg Times,
published December 11, 2001

X should mark the spot.

The Joint Commission on Accreditation of Health Care Organizations, the main accrediting agency for the nation's hospitals, last week issued a special alert to hospitals, doctors and patients aimed at preventing surgical mistakes.

Its No. 1 recommendation? Patients should insist on marking the surgical site with permanent marker.

The doctor should initial the site as well, the agency said.

The commission, which inspects and accredits 18,000 U.S. surgical centers and hospitals, including every hospital in the Tampa Bay area, issued a similar alert in 1998, but it was virtually ignored, the agency said.

It now is considering ways to include the new recommendations in the standards it uses to grade hospitals. The American College of Surgeons, the American Academy of Orthopaedic Surgeons and the American Medical Association joined the commission in issuing the alert.

"This is the first time the organizations have come together and said "Listen up, this has to stop happening.' The solution ... is so simple, it's a tragedy to see even one happening," said Charlene D. Hill, communications director for the commission.

"And we're going to consumers and saying, "Patients, you can stop this with one simple request: Sit with your surgeons and ask them to mark the surgical site."'

The advisory also suggests that each member of the surgical team confirm they have the correct patient, the correct surgical site and the correct procedure. The surgical team then should take one last "time out" before the cutting begins to check again and, if possible, confer with the patient.

The commission cited 15 cases when it issued its 1998 alert. Since then, 125 have been reported, including 11 in the past month.

Citing the experience of Florida and New York, which have led the nation in addressing wrong and wrong-site surgeries, the agency said such mistakes are grossly underreported.

Of 126 cases the commission has analyzed, 41 percent involved orthopedic or podiatric surgery, and 20 percent involved general surgery.

Overall, 76 percent of the mistakes involved operating on the wrong body part, 13 percent involved the wrong patient, and 11 percent involved the wrong surgical procedure.

The reasons for the mistakes were just as varied: Nearly 20 percent of the mistakes occurred during emergency surgery, and 16 percent of wrong-site surgeries happened because the patient was either extremely obese or had a physical deformity that skewed the operation.

Other significant reasons included time pressure to start or complete a surgery; unusual equipment or operating room set up; having multiple surgeons involved; and doing multiple procedures.

Dr. Dennis S. O'Leary, president of the commission, said all of them could easily have been prevented. "The know-how to create systems that prevent wrong-site surgeries has existed for years, yet the number of errors has not decreased," he said.

Preventing wrong-site, wrong surgery and wrong patient cases has been a priority of the Florida Board of Medicine for the past year, and Dr. Gaston J. Acosta-Rua, the board's immediate past chairman, praised the alert.

This year, the board of medicine increased penalties for surgeons who make such mistakes to include a minimum fine of $10,000. But the board has no authority over hospitals and other staff, so having the accrediting agency target the problem should have a bigger impact, he said.

"It's a failure of the system; it's not just the surgeon," said Acosta-Rua, a Jacksonville neurosurgeon. "It's the surgeon, the assistant to the surgeon, the anesthesiologist, the nurse, the hospital."

Tampa was home to one of the nation's most spectacular cases of wrong-site surgery, when patient Willie King had the wrong foot amputated in 1995 at University Community Hospital. More recently, the board disciplined a Palm Beach surgeon for mistakingly giving a penile implant to an 83-year-old who was supposed to have surgery to improve incontinence.

In 2000, the state disciplined 20 doctors for wrong or wrong-site surgery. Final numbers haven't been compiled, but the board disciplined about the same number of doctors for similar mistakes in 2001.

The commission conducts scheduled and surprise inspections of U.S. hospitals. For now, implementing the new recommendations won't be required for a hospital to win accreditation, but inspectors will ask about steps hospitals are taking to prevent wrong and wrong-site surgeries.

Eventually, hospitals that don't take appropriate steps could face sanctions.

"If they're not using our recommendations, then what are they doing to make sure it doesn't happen?" Hill said.

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