It’s the third time since 2004 that Upstate doctors have cut patients in the wrong place. “We have a zero tolerance for these type of events,” hospital CEO says
Upstate University Hospital in Syracuse has started an investigation to try to determine why a doctor made an unnecessary incision in a patient last week.Syracuse, N.Y. - An Upstate University Hospital neurosurgeon has been suspended after an unnecessary incision was made on a patient last week, the third time Upstate doctors have cut patients in the wrong place since 2004.
These blunders are known as “never events,” because health care experts say they are preventable and can cause serious harm and even death.
Hospital officials are investigating to determine how the latest error happened and what can be done to prevent similar mishaps in the future, said Dr. John McCabe, the hospital’s chief executive officer.
“We have a zero tolerance for these type of events,” McCabe said. “This administration is deadly serious about these kinds of issues.”
The hospital reported the incident to the state Health Department which is conducting its own review. The patient in the latest case was informed of the mistake and is OK, McCabe said. The mishap did not result in a “horrific patient outcome,” he said.
“But I will not downplay it,” McCabe said. “It’s an incision the patient didn’t expect to have.”
McCabe refused to disclose any details about the size of the incision or the body part involved in the latest case. But a source, speaking on the condition of anonymity, said the unnecessary cut ran almost the entire length of the patient’s back when only a relatively small incision was needed.
The surgeon’s privileges to operate at the hospital were quickly suspended, McCabe said. He would not disclose the names of the doctor or patient.
The hospital launched an investigation Monday. All the people in the case are being interviewed to determine if the mistake was caused by an individual’s lack of attention to rules, a communication breakdown, policy problems or other factors, McCabe said. The investigation could take up to two weeks, he said.
The latest incident comes on the heels of a recent state investigation which turned up numerous problems at Upstate, including a case where a neurosurgeon in training performed a complex operation on a patient’s spine without adequate supervision.
The state has cited the hospital twice since 2004 for wrong-site surgeries.
In 2004, an Upstate surgeon planning to remove a blood clot from an infant’s brain made the initial incision on the wrong side of the baby’s head. The state fined the hospital $4,000 for the mistake.
In 2006, an Upstate surgeon operated on the wrong side of a patient having a tumor removed from an adrenal gland. That mistake happened because the doctor did not double-check radiology pictures before making the incision. The state fined the hospital $10,000 for that mistake.
After the 2004 incident the state ordered Upstate to hire an outside consultant to evaluate operating room procedures and revise its pre-surgery verification routine. After the 2006 incident, the state said the corrective actions Upstate took in 2004 were inadequate.
McCabe said there is no “bullet proof” process to ensure such mistakes never happen.
“I can’t be in the operating room holding the hand of every surgeon, every time,” he said. “It’s not as simple as saying, ‘You did this before. You should have learned.’ It has to be an improvement work in progress.”
State and federal regulators have turned up the heat on hospitals in recent years to prevent these blunders. Both Medicare and Medicaid have stopped paying hospitals for cases involving wrong-site surgery and other “never events.”
The state Health Department and the Joint Commission, the agency that accredits U.S. hospitals, require hospitals to call “timeouts” before operations begin so doctors and others take the time to double-check they are doing the right operation, on the right patient, in the right location. Surgical sites also must be marked with indelible markers to help prevent mistakes.
Before last week’s surgical mistake, the patient’s surgical site was marked appropriately and staff conducted a timeout, according to McCabe. The hospital investigation is looking to see if every item on the timeout checklist was completed, he said.
James T. Mulder can be reached at 470-2245 or jmulder@syracuse.com