Nine Wrong-Site Surgeries Occurred in Utah Hospitals in 2007

Utah hospitals and surgical centers reported 57 “never events,” described as errors in medical care that are clearly preventable and serious in consequence for patients, last year. That's about one every six days.

These types of tragedies are never supposed to happen, but they do. In December, last year, a man walked into the emergency room at Uintah Basin Medical Center feeling weak, tired and short of breath.

It was determined that he was extremely anemic and in need of a blood transfusion. The hospital staff started him on a unit of A+ blood. Only, the man’s blood type was O+.

Seven hours later he died. He was given blood intended for another patient with a similar name.

The error was blamed hospital staff failing to match-up labels between the blood and patient name at the hospital blood bank or when the blood was brought to his room, according to an investigative review by the state health department.

A breakdown of reported never events shows – 27 patients died and 28 were gravely injured – losing mental or physical function, last year.

Other reported errors include a patient with a bed sore that spread beneath the skin and a ten-year-old baby who suffered a skull fracture when a staff member dropped the child on the floor.

That is not all of them, there were more, including the disappearance of a patient and non-consensual sexual contact of another.

In 2001, following a study by the Institute of Medicine (IOM) titled “To Err is Human: Building a Safer Health System,” Utah began monitoring never events, also referred to as sentinel events.

The IOM estimates medical errors cause up to 98,000 deaths a year.

Serious errors voluntarily reported by Utah facilities continue to rise, in part, because the state increased the number of qualifying errors last year.

Utah keeps track of 32 types of serious errors, which are defined as permanent loss of function not related to the patients’ condition or illness, such as medication errors, criminal events of any kind and wrong site surgeries.

An estimated 350 deaths occur each year, in Utah, in conjunction with medical errors, according to Iona Thraen, director of patient safety for the health department.

The numbers are sobering for wrong-site surgeries and medication errors. Despite a statewide campaign to standardize the way surgeries are handled in operating rooms, surgical errors continue to rise.

Nine surgeries were done on the wrong site or the wrong surgery was performed, in Utah last year. Of those, seven include foreign objects being left inside the patient.

Data shows medical errors are more prevalent in men and occur in operating rooms most frequently. The cause is likely threefold - lack of communication among hospital staff and lack of patient monitoring and assessment, according to the state and the Utah Hospitals and Health Systems Association.

“Utah hospitals are committed to eliminating preventable medical and surgical errors,” said Debra Wynkoop, of Division of Health Systems Improvement. “We don’t find it acceptable.” #