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Did you ever think that when you check into the hospital for surgery you may end up missing a perfectly good kidney and your bum kidney still in place? If it wasn’t so serious it could have been the opening line of a Joke (“there was this guy who checked into the hospital…”).

A paper in the October 2010 Archives of Surgery is nothing if not alarming. In brief, the researchers examined the insurance records of 27,370 physicians in Colorado who reported adverse occurrences over a period of 6.5 years. Highlights of their findings:

  • They operated on the right site but the wrong patient at least 25 times.
  • Right patient, wrong site: 107 patients.
  • The wrong-site wrong-patient occurrences made up 0.5% of all medical mistakes analyzed in the study
  • The authors estimate that the actual number is much higher; this is the tip of the iceberg.

Why are we having so many catastrophic “never events”? If we add the wrong-site and the wrong-patient episodes we get 132 over 6.5 years. Considering the total number of surgeons in Colorado, my guess is that almost every surgeon in the state has seen one. Is this problem endemic to Colorado? Of course not. The state has a great medical center and many excellent physicians. Colorado is a window into a nationwide problem.

The Causes

  • The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a “time-out” (72.0%)
  • About half of the mishaps resulted from the non-surgical specialties. These include wrong diagnoses by the internist, mixing up patient records, wrong X- rays, wrong biopsy samples.
  • The surgical staff accounted for the rest of the mistakes: a nurse identifying the wrong organ, the surgeon relying on memory.


Errors in communication were involved in 100% of all occurrences. I am no expert on Electronic Medical Records (EMR), but at this day and age keeping a patient’s records in dusty paper files? Carrying X-rays by hand to the doctor’s office? Ordering lab tests on a piece of paper?

Kaiser Permanente computerized all its medical records; when you see a doctor she gets all your past medical history instantaneously on her computer screen. I am a Kaiser member and recently went to see a doctor at a drop-in for a minor rash. She looked at my records and saw that I had had bronchitis a few weeks before. She listened to my lungs, and while we were at it –ordered a flu shot to bring me up to date on my immunizations. Superb medical care, made possible by EMR.

And yet, according to well-respected studies from the Rand Corp., roughly half the time doctors fail to provide the right preventive and acute medical care for adults and children for everything from ear infections to heart attacks to sexually transmitted diseases. Doctors long ago discovered treatments for the conditions. Why, then, do they so often fail to apply them correctly?

Timeouts and checklists

Lack of performing “timeouts” was involved in 72% of the cases. What is the surgical team supposed to do during “time out”? No, they don’t meditate or take a nap. Simply put, they use a checklist of all the steps that lead up to the operative procedure. Think of the pilots going through their checklist before every takeoff. Would you fly an airline that doesn’t make it 0.5% of the time (in case you are having trouble thinking in abstract percentages –it is 1 in 200 flights)?

In his book “The Checklist Manifesto” Atul Gawande, a Harvard surgeon, and writer notes that there are two reasons for failure: ignorance (not yet knowing how to do something) and ineptitude (failing to apply what is already known). The former can be forgiven, but the latter rightly arouses anger and judgment.

Gawande describes the case of the spectacular crash of Boeing’s “flying fortress” test bomber in 1935. As a response, Boeing engineers created an index-card-size checklist of critical tasks that was so effective, not a single of the 13,000 planes ever crashed again. These checklists, argues Gawande, should be widely used in healthcare. The successful ones accomplish two things. First, they ensure that narrowly specific “stupid stuff” isn’t missed, like allergies or proper antibiotics. Just as important, the checklists also build in communication checks to ensure people work as a team.

Sharing information on successes

Are checklists the panacea? There are no silver bullets. Consider another paper in the Archives of Surgery of the same date: 16 Michigan hospitals cut surgery complications by 10 percent, saving millions in medical costs, by sharing information about the methods they used to keep patients safe. The hospitals could save $13 million a year on cases of ventilator-associated pneumonia alone. More than 315,000 patients were involved in the study, which focused on general and vascular surgeries from April 2005 through December 2007. As part of the Michigan Surgical Quality Collaborative, the competing hospitals pooled information to determine which practices were most effective at preventing surgical complications and then put those best practices into effect. The hospitals saw the greatest reduction in the following complications: blood infections, septic shock, prolonged ventilator use, and cardiac arrest.

Appropriate use of antibiotics

Shoddy clinical practices are not limited to the surgical specialties. Antibiotics are prescribed willy-nilly for every earache (a majority of which are viral and self-limiting), flu-like symptoms and bronchitis (mostly viral as well). In the mid-90’s Dr. Salber (yes, THE Dr. Salber of this blog), in her capacity as Leader of the Kaiser Permanente/ General Motors healthcare collaboration founded MARR (Michigan Antibiotic Resistance Reduction) program. It brought together General Motors, Ford, other businesses, the three state medical school, Public Health, and practitioners, in an educational and collaborative practice information exchange to reduce the antibiotic resistance problem. This is not a trivial issue; we are quickly running out of effective antibiotics to treat the deadly MRSA infection, and complications of inappropriate use can result in the dangerous C. difficile infection.

Now, just imagine if such Michigan-style collaborations were adopted nationwide. What is it about Michigan that cannot be replicated in Colorado or all 50 states?

Believe it or not: the new health care bill actually promotes the use of EMR, of checklists, of state and national collaborations and setting of practice standards. So why is there such vehement resistance? Answer: too many powerful interests invested in the status quo, and only a few feeble voices advocating the patients’ welfare.

It boggles the mind.

This post was reviewed and updated on 11/124/18.

Dov Michaeli, MD, PhD
Dov Michaeli, MD, PhD loves to write about the brain and human behavior as well as translate complicated basic science concepts into entertainment for the rest of us. He was a professor at the University of California San Francisco before leaving to enter the world of biotech. He served as the Chief Medical Officer of biotech companies, including Aphton Corporation. He also founded and served as the CEO of Madah Medica, an early stage biotech company developing products to improve post-surgical pain control. He is now retired and enjoys working out, following the stock market, travelling the world, and, of course, writing for TDWI.


  1. Stories like this really worry me. I went to the ER once with an infection that was really obvious. I’d waited way too long and the doc sent me over. I got to the ER and they asked me what they could do for me without even looking at my face. Then they looked up and were like “oh!’ They still didn’t do anything. I heard them talking and they asked each other what they were supposed to do about it. Didn’t even give me antibiotics. I had to go back to my GP for those. That has been a typical experience for me. Healthcare is really crappy where I live.

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