The Agency for Healthcare Research and Quality (AHRQ) describes “wrong-site, wrong-procedure, wrong-patient errors" as “never events”. Unfortunately, in medicine never does not always mean never. According to a seminal AHRQ supported study, published in 2006, the incidence of wrong site surgery is 1 in 112,994.
In August, CNN reported that the Massachusetts Department of Health was investigating a case where a kidney was removed from the wrong patient at St. Vincent’s Hospital in Worcester, MA. Before a patient gets to the operating room they are typically seen pre-operatively by several members of the surgical team. Each team member acts as a check against wrong-site, wrong-procedure, wrong-patient errors. Ideally, the procedure has been confirmed with the patient multiple times before the patient arrives in the OR - by the surgeon, anesthesiologist and other members of the medical staff. However, the “time-out” procedure in the OR, which entails a verbal confirmation among the surgical team prior to beginning surgery, is the final and official confirmation that the correct procedure is performed on the correct patient at the correct site.
Unfortunately, the “time-out” is only effective if the medical staff take it seriously and treat it as an opportunity to ensure the safety of their patient. For many medical professionals the “time-out” seems unnecessary - a procedural hurdle that must be completed before the real work begins. Most surgeons can’t fathom the idea of operating on the wrong patient or site. But the case at St. Vincent’s is clear evidence that while rare, these events can happen, if procedures such as the “time-out” are not treated as vital and necessary pre-operative measures.
Read more about the case at St. Vincent’s Hospital here: http://www.cnn.com/2016/08/10/health/kidney-removed-from-wrong-patient/