Doctors suspended for removing wrong kidney

Phil Peacock's suggestion just has one flaw - If the doctor
organising the surgery had written 'Not this one' on the wrong side it
would produce a problem rather than a solution.

Competing interests:
None declared

What is reported is a chilling example of negligence which led to
irreparable damage to a patient.

Wrong person, wrong procedure, wrong site surgery can obviously lead
to devastating and tragic consequences. Many agencies had realized it.

I would like to bring the following development in USA to the notice
of all readers of this journal.On December 2, 2003, more than 40 medical,
nursing and healthcare leadership associations and organizations in USA,
joined the Joint Commission on Accreditation of Health Care Organization
(JCAOH) and endorsed a new Universal Protocol to standardize pre-surgery
procedures, to verify the correct patient, the correct procedure and the
correct surgical site.

Currently, all accredited hospitals, ambulatory care and office based
surgical facilities in USA are being strongly encouraged to comply with
the protocol; They will be required to do so from July 1, 2004.

The Protocol has many elements. The patient has to be positively
identified before operation; the operative site has to be marked; the
operating staff should take a "time out" immediately before starting the
procedure to double check information among all members of the surgical
team.

The initiative emerged from a worrying historical background.In 1998,
the Insitute of Medicine set up the Quality in Healthcare in America
Committee to plan improvements in healthcare quality for the next decade.
An important facet of that effort was to reduce medical errors and to
increase attention to patient safety.

The first report from the Institute published in 1999 contained some
chilling facts. A study conducted in Colorado and Utah found that adverse
events occurred in 2.9 percent of hospitalizations. In another study in
New York, the corresponding figure was 3.7 percent! In Colorado and Utah
hospitals, 6.6 percent of adverse events led to death, as compared with
13.6 percent in New York hospitals. Believe it or not, half of these
adverse events resulted from medical errors and could have been prevented.

The lower estimate of deaths due to medical errors is about 44,000.
Based on the data for 1997, the report concluded that in USA, more people
die in a given year as a result of medical errors than from motor vehicle
accidents (43,458), breast cancer (42,297), or AIDS (16,516)

Some experts disputed these numbers; but everyone agreed that patient
safety is an important issue that deserved attention. IOM report was
indeed a wake up call

Instances of wrong site surgery may be very few. But that is poor
consolation for a patient who has to suffer the consequences. According to
JCAHO, surgeons made errors during surgery 150 times since 1996. The
agency alerted the patients to be more involved in ensuring that the
surgical site is well marked before undergoing surgery. Of the 150 cases
in its database, operations on the wrong part was 76%; the operations on
the wrong patient were 13% of the cases; eleven percent of the cases
involved wrong surgical procedures

Though everyone acknowledges that medical errors in surgery are
entirely preventable, JCAHO continues to receive five to eight new reports
of wrong site surgery every month from organizations that provide surgical
services

In response to the alerts of JCAHO, the American Academy of
Orthopaedic Surgeons adopted a "Sign your Site" programme of preoperative
surgical site identification. Surgeons were encouraged to initial the
intended surgical site using a permanent marke.After a two year period of
this campaign, only 60 % of physicians were marking their operative sites.

By far the most infamous incident reported by the media in India and
USA occurred at Memorial Sloan-Kettering Cancer Center, New York. Dr.Ehud
Arbit a neurosurgeon at the hospital operated on the wrong side of the
brain of a patient from India.

" Physicians Weekly" (May 4,1996 Vol.XIII,No.6) gave the following details: As Memorial's
neurosurgeon Joseph Galicich Jr was about to retire , he referred his
patient, Mrs Rajeswari Ayyappan, the mother of film star Sridevi, via his
secretary to Dr. Arbit. Dr Arbit operated the right side of her brain on
May 26, 1995; actually she had cancer on the left side

Dr Arbit thought that a 59 year old man from New Delhi was on the
operating table. The name of that patient was Gupta. He had cancer on the
right side of his brain

Dr Arbit thought that his secretary who left a note about a patient
from India was referring to Gupta, whose records he had already received.
After reading those records Arbit decided that the surgery could be done
in India. Not knowing the the Gupta connection, his secretary called
Rajeswari's family for discussion with Dr Arbit. Dr Arbit thought that he
was talking to the family members of Gupta. They insisted on surgery at
the Memorial.

Dr Arbit was suspended on June 8,1995; subsequently,he received a Censure and Reprimand, one year probation including practice monitoring and a $10,000 fine after signing in a consent order in which he agreed not to contest the Department's charges.

Dr Arbit later became director of neurosurgical oncology, Staten
Island University Hospital. On January 5, 2001, the New York State Health
Department found that Dr Arbit committed gross professional misconduct.
This time the charge was that he operated on the wrong part of a patient's
spine.

I believe that all countries should implement the Universal protocol
to avoid surgical errors.It must have the force of law.It may inevitably
called "the Universal right of patients".

Competing interests:
None declared