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VOL. 113 | NO. 13 | Thursday, January 21, 1999

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By STACEY PETSCHAUER X marks the spot Surgeons are increasingly using a $1.50 instrument to ensure they operate on the right part of a patient By STACEY PETSCHAUER The Daily News What kind of insurance policy can someone buy for $1.50? If that someone happens to be a surgeon, a very beneficial one. A problem encountered by physicians in the operating room is being addressed by an inexpensive piece of medical equipment a $1.50 marking pen. Various medical blunders, some of which were serious enough to be considered full-blown catastrophes, have spawned a movement led by orthopedic surgeons to end "wrong-site surgery," the performance of a surgical procedure on the wrong side or wrong part of a patients body. The movement urges physicians who are about to operate to sign the spot on a patients body marked for surgery with an indelible ink pen before wielding the knife. Dr. S. Terry Canale, chief of staff with the Campbell Clinic in Memphis and first vice president of the American Academy of Orthopedic Surgeons, is leading the academys crusade to end wrong-site surgery. A surgeons signature, in addition to providing a pre-operative consultation with the patient, is a simple solution to a rare but potentially devastating problem, the AAOS found. A particularly disastrous example of wrong-site surgery occurred in 1983, when a group of California surgeons removed the wrong kidney from a patient, leaving one kidney that was one-fifth its normal size. The patient received $250,000 in damages for the mistake but lived out the remaining 13 years of his life in pain. In another incident that occurred in Florida, a surgeon amputated the wrong foot. The patient collected $1.2 million for the error. Not only do wrong site surgical mistakes cause physical damage to patients and emotional damage for surgeons, they often result in serious malpractice implications. The bottom line is, these situations are entirely avoidable, Canale said. "There are things in surgery that are complications and this is one of them that the surgeon, the patient, the anesthesiologist and the nurses dont know is coming, like infection or nerve damage or something like that thats just not preventable," he said. "However, this particular problem or complication is preventable. That is the beauty of this. If we can get the message out, we can stop wrong-site surgery from occurring." Since the AAOS decided to support this program, its main objective has been getting the message out about wrong-site surgery. The academy began publicizing the program nationally as soon as it was approved about one year ago by sending letters to all U.S. operating rooms and surgical training programs. A recent survey conducted by the academy found 88 percent of surgeons across the country have heard of and approve of the program. Likewise, 40 percent of U.S. surgeons have become compliant with the program within its first year. One reason is probability. If a physician practices orthopedic surgery for 30 years, the surgeon has a one in four chance of performing a wrong site surgical procedure during the course of his or her career, said Dr. James D. Heckman, president of the AAOS and a physician at the University of Texas at San Antonio Health Science Center. "So, if you are in a four-man group, somebody in that group is going to have this happen to them," Heckman said. Wrong-site surgery can occur for several reasons, including backward X-rays, misread medical charts and botched pre-operative work-ups. The practice of signing the site to prevent these errors is catching on, but slowly, Heckman said. "It requires a change in behavior, and any time you try to change somebodys behavior, it takes a long time," he said. "But it is becoming institutionalized in some hospitals, and that is the secret to its success. "One surgeon can do it, and thats great, but its much better if it gets institutionalized, so that all the surgeons are doing it, and the anesthesiologists and nurses, everybodys on board and committed to it," Heckman said. He said his hospital is going through the final phases of implementing the program institutionally. The Campbell Clinic has been practicing the program since its approval, Canale said. The program got its start about two years ago when Heckman assigned Canale and several other surgeons to look at what could be done to stop wrong-site procedures, said Mark Wieting, vice president for education programs at the AAOS headquarters in Chicago. The group learned Canadian surgeons had tried to address the problem and were recommending that all surgeons sign their initials on operative sites. "Our feeling was that if we could do that, if we could get as many people as possible to do that every time, we would have a good shot at really reducing if not eliminating wrong-site surgery," Wieting said. Dr. Jim Beaty, a surgeon at the Campbell Clinic, has made site-signing a part of his regular pre-operative routine. He said with some orthopedic surgery procedures, there are obvious deformities that would make wrong-site surgery highly unlikely. But, there are other procedures, particularly joint-related operations, in which the problems are very difficult to locate without charts and X-rays. Beaty said he believes it is important to sign initials on every surgery site, however, in order to get into a routine and thus reduce the chance of making an unnecessary error. He marks patients as one of the last things he does before the patient goes under the knife. "The usual response is, Well, yeah, Im kind of glad youre doing that. Because they wouldnt want to be the one patient that had their surgery on the wrong side," Beaty said. Canale said he believes the site-signing procedure gives patients a sense of confidence right before an operation. "What it really does, also, is allow the surgeon to see the patient pre-operatively and talk to them before putting the mark on the extremity," Canale said. "It reassures the patient that theyve talked to their surgeon, and it also helps the physician to know that hes checked the chart, checked the X-rays, talked to the patient, looked at the operative permit and has signed, in accordance with all that, the correct site. "So, it is more than just putting your initials somewhere. Its sort of a systems review," Canale said. He said the only negative he can find with the program is not really a negative. "Sometimes it takes a little bit longer to stop what you are doing and talk to the patient, but if you call that a negative, then there is something wrong with our system," he said. The site-signing procedure also can protect physicians from malpractice cases, which usually are settled out of court and almost always award monetary settlements to patients. Jeffrey Jones, a Memphis attorney who handles personal injury cases, including malpractice cases, once dealt with a situation in which a client underwent wrong-site surgery for lung cancer. The cancer was in the left lobe, and physicians went in on the right. Since the surgeons had to crack the mans chest with a surgical saw for the procedure, they were not immediately able to go in on the other side. The patient was forced to wait three to four weeks for completion of the procedure on the correct lung. The error occurred because the surgeon had a working arrangement with his scrub nurses and technicians that patients feet always would be pointed toward the south. That day, apparently, the patient was facing north, Jones said. "Virtually all the times something like this happens, the surgeon is more or less relying on the work-up," Jones said. "But the surgeon is ultimately responsible for the surgery. He can only so much explain that he was relying on the work-up of the nurses or the technicians or whomever. "The law does not allow him to pass off that liability to somebody else," he said. So, it is to a surgeons benefit to take the extra time to consult with his or her patient and make certain the knife enters the correctly initialed area of the body. "If you look at the reports of the malpractice insurance carriers in this country, there is not a very large number, but there are episodes of operating on the wrong limb that occur consistently, on a fairly regular basis, around the country, regardless of who the surgeon is," Heckman said. "So, we are trying to eliminate an avoidable problem that is devastating for the patient and the physician."
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