Minnesota hospitals have struggled for years to eliminate so-called wrong-site surgeries such as the one that occurred last week when a Methodist Hospital surgeon accidentally removed a healthy kidney from a patient with kidney cancer.
But just as soon as they think they've made progress, they find another gap in their safety protocols. In this case, the mistake happened because weeks before the patient was rolled into the surgery suite, the surgeon marked the wrong kidney as cancerous in the medical record.
Patient safety experts say they are just beginning to realize that correcting such upstream mistakes in medical records will be critically important in eliminating wrong-site surgeries. But those fixes will be far more complicated and difficult to implement than safety protocols that primarily focus on operating rooms just before surgery.
Kathleen Harder, a University of Minnesota psychologist working with Minnesota hospitals to reduce errors, believes it is possible to design ways for hospitals to get better.
"Having said that, however, you will never completely eradicate human errors," she said. "Because humans are humans."
Often, it takes a serious error to spark reforms, said Chris Messerly, a Minneapolis attorney who specializes in medical malpractice cases.
In the wake of the tragic error that resulted in leaving a cancerous kidney in the patient, Methodist has again refined its procedures, officials said. To prevent that kind of thing from happening again, as of Monday surgical teams at Methodist are required to review all medical images, such as X-rays, right before surgery begins. It will be yet another item on their last-minute safety checklist.
"This is an event that points out how complicated wrong-site surgeries can be," said Diane Rydrych, assistant director of healthy policy at the Minnesota Department of Health. "There are a lot of steps that have to happen correctly, and errors can occur at any time."
Officials from Park Nicollet Health Services, which owns the St. Louis Park hospital, took the unusual step of going public with what many described as an extremely rare event. In doing so, they shed light on how what was once a secretive process within each hospital has become a national and statewide public health effort to reduce hospital errors.
"Being transparent is a major step forward in patient safety," Rydrych said.
Methodist officials said they have apologized to the patient and family, who asked not to be identified, and are providing support in every way they can. They declined to say what effect the error will have on the patient's chances for recovery.
The surgeon, who also was not identified, has voluntarily stopped seeing patients until the hospital completes its internal inquiry.
Once completed, that inquiry will be shared with the Health Department and other hospitals around the state, as required by state law.
How safety protocols work
Minnesota was the first state to adopt national error reporting guidelines, which require hospitals to report a variety of errors, including wrong-site surgeries. In addition, Minnesota hospitals now share information and tricks-of-the-trade to reduce errors.
To date, most of the protocols to prevent wrong-site surgeries occur in the operating room. Surgeons, for example, now routinely mark the surgical site on the patient while the patient is awake. Surgical teams routinely "pause for the cause," where they take a moment to review the case before they proceed. Anyone with doubts or questions is expected to speak up.
But there's no doubt, experts say, that mistakes still slip through. Last year hospitals in the state reported 24 wrong-site surgeries, though none resulted in death or serious disability, according to an annual report by the Health Department.
Dr. David Dries, a surgeon at Regions Hospital in St. Paul, recently studied the surgical mishaps at Minnesota hospitals. In more than half, surgeons who operated on the wrong body part failed to sign or initial the spot ahead of time. In one case, he said, a surgeon admitted he was thinking about his next case when he performed the wrong operation.
Dries, who is president-elect of the Minnesota Surgical Society, said such mistakes "are devastating for any surgeon."
How mistakes happen
But in every case he examined, he found that surgical teams ignored at least one of the safety rules imposed to prevent such errors. The rules may work, he said, "but we don't always follow them."
Mistakes can happen even if all the rules are followed. Methodist Hospital officials said that was the case with the kidney cancer patient.
Now patient safety experts are trying to untangle how errors take root before surgery begins, Rydrych said "We're talking to hospitals about how to make sure that we are looking at all the available documentation and information prior to the procedure. There's not a lot of research on that."
Because every hospital and every clinic has a different system, "it's a huge task," she said.
Messerly, the attorney, gives Park Nicollet credit for being open about the situation. "My hat's off to Park Nicollet for being upright," which he views as key to progress.
A few years ago, he represented a woman who was given a double mastectomy when she was wrongly diagnosed with breast cancer. That case prompted changes in pathology labs around the country. "There's a lot of good that can come out of such a horrible tragedy," he said.