Operating on the wrong knee, testicle or kidney can happen in a rush or because of miscommunication. Although these types of surgical errors are rare, they continue to occur. However, these incidents can be avoided with a few measures and a simple tool.
- Side errors are even more common than you might think. with a high number of these incidents during orthopedic and ophthalmological surgeries.
- These incidents would occur due to haste, poor communication within the medical team, absence or incorrect use of the surgical checklist.
- To prevent these surgical errors, it is necessary to implement a standardized protocol for marking the surgical site, verifying the clinical history and imaging tests, and using the checklist that precedes each intervention in an appropriate manner.
A “human error”. In Austria, a surgeon was fined 2,700 euros on December 1, half of which was suspended, for having amputated the bad leg of an 82-year-old man. The nurse had made a mistake and had indicated the member not to operate before the surgery last May in Freistadt. She realized this two days after the operation. The Linz Regional Court judge found the surgeon guilty of “gross negligent injury”. He also awarded 5,000 euros in damages to the widow of the patient, who died in the meantime. The defendant denounced a flaw in the chain of control in the operating room. The clinic management said that “the causes and circumstances of this medical error had been analyzed with precision”.
An underestimation of side errors
According to a spanish study, presented at the 2019 Euroanaesthesia Congress, so-called “sideways” errors are not as rare as one might think. Researchers at the Universitario Fundación Alcorcón Hospital in Madrid, Spain, wanted to determine their frequency, the reasons for their occurrence and the safety mechanisms needed to prevent them. To do this, they analyzed incidents reported in the Spanish Safety Reporting System in Anesthesia and Resuscitation (SENSAR), a system that collected data from 100 Spanish hospitals between 2007 and 2018.
Overall, 81 lateral errors have been reported over 11 years, with a high number of these incidents during orthopedic and ophthalmological surgeries. According to the results, 44% of these side errors were related to the surgical procedure and 56% related to the anesthesia technique, specifically anesthesia on the wrong side of the body. “The harsh reality is that due to the lack of reports of these types of incidents in the databases, these figures are likely to represent an underestimate of reality. However, in recent years, the implementation of the reporting of unwanted errors has enabled the adoption of corrective measures to reduce their occurrence in our hospitals”explained Dr. Daniel Arnal, lead author of the study.
A marking protocol to avoid side errors
Researchers have revealed the origins of these side errors and system failures. In two-thirds of cases, the surgical checklist, i.e. a document which makes it possible to check the essential criteria before any operation, is badly or not used. Other causes: haste and poor communication within the medical team.
“Although these serious adverse events are extremely rare, our mission should be to reduce them to zero,” said Dr. Daniel Arnal. To prevent side errors from occurring, the scientists highlighted the need for the implementation of a standardized protocol for marking the surgical site and the careful review of clinical history and imaging tests. They also reiterated the importance of patient involvement for their own safety, adequate training and proper use of the surgical checklist. In France, according to the Haute Autorité de Santé (HAS), correct use of the checklist led to a decrease in postoperative complications by almost 30%.
Remedies for victims of a side error
This does not prevent the fact that in our country 60,000 to 95,000 serious adverse events occur each year, still according to the High Authority for Health. In the event of side errors, the victims can undertake an amicable settlement with the professional or the health establishment involved in the medical accident. “It is also possible to refer cases to the Regional Commission for Conciliation and Compensation (CRCI). Responsible for deciding on possible compensation for victims of medical errors, this free and independent system does not require assistance of a lawyer”can we read on the website of the France Assos Santé association.
If the surgical error involves a liberal health professional or a private health establishment, the dispute must be judged by the high court. The administrative court, for its part, is responsible for judging medical errors suffered in a public health establishment or through the intermediary of a professional practicing as an employee of a public establishment. “In both cases, to hope for compensation, the victim must provide medical expertise, the costs of which are at his expense and the use of a lawyer is mandatory”, specifies the association.
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