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Your surgery's on the left, right?; Mistakes: Doctors horrified by accounts of operations on the wrong limb increasingly are labeling the correct site with indelible ink.


Don't be alarmed -- your surgeon is just making sure.

At Union Memorial Hospital, Dr. Les Matthews writes "yes" on one knee, "no" on the other.

At St. Joseph Medical Center, Dr. Kenneth C. Gertson scribbles his initials on the limb he wants to repair.

At Kernan Hospital, Dr. Kevin Tetsworth marks the spot with an X.

And at Greater Baltimore Medical Center, nurses and doctors wielding felt-tip pens ask ophthalmology patients the same stupefyingly simple question.

"So we're doing the left eye today?" Dr. Kerry Rowan asked Barry Magness outside the operating room recently before scrawling a green X above his eyebrow.

Surgeons across the country are marking up their patients to avoid one of the most horrifying but preventable errors in medicine: operating on the wrong body part. Thousands are doing so in the wake of some well-publicized mistakes and a campaign by a leading surgical society.

In September, the American Academy of Orthopedic Surgery began mailing "Sign Your Site" letters to doctors across the country. The letter urges them to initial the surgical site with indelible ink just before the patient is anesthetized.

"There are a lot of things in life, including a lot of complications of surgery, that are not preventable," said Dr. S. Terry Canale of Memphis, Tenn., secretary of the orthopedic academy. "But wrong-site surgery is preventable."

The campaign comes at a time when doctors are awakening slowly -- and reluctantly -- to the problem of human error in medical care. A 1993 Harvard report brought the issue into sharp focus: Researchers estimated that 1 million people are injured and 120,000 killed each year in U.S. hospitals as a result of mistakes that could have been prevented.

Medication errors were by far the leading culprit, accounting for almost 20 percent of the deaths and injuries. Recently, many hospitals have built safeguards into their systems of dispensing drugs.

At the University of Maryland Medical Center, pharmacists transcribe doctors' handwritten orders into a computer, which is programmed to flag potential drug overdoses and adverse reactions. At Johns Hopkins Hospital, internists type their own prescriptions at computer terminals rather than asking others to make sense of the handwriting.

More frequent than thought

Operating on the wrong site is relatively rare, but the orthopedic society says it happens more frequently than doctors or patients would like to think. In a survey of 110,000 physicians, a national insurance association counted 331 suits for wrong-site surgery between 1985 and 1995 -- two thirds of them against orthopedists.

A few shocking cases have drawn public attention, such as a Tampa, Fla., surgeon who amputated the wrong leg of a patient who suffered from circulatory problems on both sides. In another incident, a New York neurosurgeon inserted an instrument into the wrong side of a patient's brain before discovering his error.

Most cases are less dramatic than these. Many involve confusing left and right during arthroscopic surgery on knees, hands or feet -- relatively simple repairs in which surgeons insert slim instruments through tiny incisions.

Errors can occur when a technician marks an X-ray as "right" rather than "left," when someone makes the wrong notation on a surgical schedule, when an aide shaves the wrong leg or when a surgeon gets confused after the seventh or eighth operation of the day.

Though few surgeons confess to having operated on the wrong limb, most can remember times when a potential error was caught moments before surgery. Matthews, chief of orthopedics at Union Memorial, said every surgeon has seen errors on operating schedules and mislabeled X-rays.

"I've even seen patients who know that the opposite knee is being prepared for surgery but don't say a word," he said.

Matthews said "three or four" patients have come to him after surgeons elsewhere operated on the wrong side. He said he's had a hand in one such mishap in his 18-year career, "a very brief arthroscopic evaluation of the wrong knee." There were no complications, he said, and no litigation.

"There was a total breakdown in the system," he said. "The patient was not marked. The person who asked the patient [before surgery] wasn't present after the patient went to sleep. The schedule was printed wrong. They prepped the wrong knee."

Confirmation by 5

Recognizing that the surgeon is ultimately responsible, Matthews says he makes a point of marking one limb "yes" and the other "no" after checking with the patient in the operating room. Before he sees the patient, "no fewer than five people -- from the nurse to the anesthesiologist -- should confirm with that patient which side should be operated on."

Johns Hopkins Hospital requires its orthopedic surgeons to clearly indicate "left" or "right" on its operating room schedules, and surgery is not supposed to begin until every doctor and nurse in attendance agrees. Dr. Beryl Rosenstein, vice president for medical affairs, said requiring surgeons to draw on the patient is under consideration.

Some doctors do it on their own, including Dr. Michael Ain, who said he has been writing "no" on the wrong knee since hearing about an unfortunate incident at the Albany, N.Y., hospital where he trained. There, a boy woke up from anesthesia to find the wrong knee bandaged after arthroscopic surgery.

'Wrong' bandage

"He asked, 'Why is the bandage on wrong?' " said Ain, a pediatric orthopedist. "It's not like taking somebody's leg off, but it's bad."

GBMC's administration is also considering a policy that would require all surgeons to mark their site before surgery. Over the past two years, most of the hospital's ophthalmologists but only a few of the orthopedists have taken up the practice.

"I think it's a great idea -- there are no negatives at all," said Dr. Charles P. Wilkinson, chief of ophthalmology at GBMC.

Dr. Michael Sheerer, a GBMC orthopedist, said he suspects he will end up doing it himself one day but wonders whether there is a hidden flaw.

"It sounds like a great idea, but there isn't a situation around that isn't fail-safe," he said. "People can develop a system that everyone assumes is foolproof, but then there's a problem."

Sheerer said he is acutely aware of the potential for error and checks with his patients "literally minutes or seconds" before anesthesia is given.

"I get really upset if I'm hung up on the phone and they've sedated a patient before I come in," Sheerer said.

Some patients are taking no chances. In Chicago, one patient scrawled a note on his arm -- "I hurt here," with an arrow pointing to his elbow. In New York, a patient tied a pink ribbon around her injured leg.

"I had a patient who wrote on the opposite knee, 'Not this one stupid!' " said Sheerer. "Maybe three weeks ago, someone put on the good knee, 'Go away.' "

Pub Date: 2/03/99

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