The day he made the mistake, the surgeon at Regions Hospital jumped the gun. ¶ He was supposed to wait for the "timeout," when everyone in the operating room pauses to make sure that the right patient is getting the right operation.
But in December 2007, the surgeon skipped that step, picked up the scalpel and made the first incision -- in the wrong spot.
The patient wasn't seriously harmed, said Dana Langness, senior director of surgical services at Regions in St. Paul. But for Langness, it was another frustrating reminder of how easily patients can slip through the safety net inside the operating room and grave medical errors can occur.
In the past few years, Regions and other hospitals have piled on new safety rules in a growing effort to prevent surgical errors. But they've found, to their dismay, that people keep making the same mistakes in spite of them.
Since 2003, 150 surgical mix-ups have been reported throughout Minnesota, including 97 operations on the wrong body part and nine on the wrong patient, according to a Jan. 16 report from the state health department. Although rare, these headline-grabbing episodes are just a slice of a broader problem of hospital medical errors that affect thousands of patients nationally every year.
As a result, hospital officials are experimenting with new ways to prevent mistakes. One of them is as simple as a cloth.
Last year, after the operating-room blunder, staffers at Regions designed what they call a "timeout towel" to cover surgical instruments before operations. Now any surgeon who reaches for the scalpel too soon -- before the safety rituals are complete -- is greeted with the words "Time-Out!" emblazoned in red.
It might seem like a small thing. But at Regions and elsewhere, experts in patient safety have found that it's not enough to put new rules in place. They have to make sure that people under pressure pay attention to them. That often involves changing deeply embedded habits -- and that's been a lot tougher than expected.
