Given the vast array of medical tasks that doctors perform, their depth of knowledge and the seriousness of their profession, it is easy to forget they are not immune to human errors. Catastrophic surgical, human errors are "a lot more common than the public thinks," says Dr. Martin Makary, a professor of surgery and public health at John Hopkins University, in Baltimore.

In order to minimise the risk of this, The Joint Commission, a not-for profit that accredits medical organisations in America, produced a Universal Protocol. It is a set of steps, developed through expert consensus, that helps prevent what is known as wrong-person, wrong-procedure, wrong-site and wrong-surgery (WSS) – or sentinel events.

The Universal Protocol directs the systematic use of surgical site marking, a preoperative checklist, and a time-out immediately before incision as effective and necessary steps to be practiced by every surgeon. The time-out is meant to give doctors those spare few minutes to ensure that the patient, surgical site and procedure to be conducted is accurate.

1. Wrong person

A study that observed doctors in Colorado over a period of six and a half years, found they operated on the wrong patient at least 25 times. "Each hospital, whether they publicly admit it or not, and whether or not it's discoverable in a lawsuit, has an episode of wrong-patient surgery either every year or once every few years," Dr. Makary said.

One of the most tragic stories is that of a pregnant woman who was scheduled to have her appendix removed in 2011. Instead, her ovary was removed, leaving the infected appendix inside her. The woman was readmitted to the hospital three weeks later when the mistake was discovered, but unfortunately, she miscarried and died on the operating table.

2. Wrong site

The final of the sentinel events, correct surgery, but on the wrong part of the body, invariably leads to areas of the body malfunctioning, where before they did not. A well-known story of medical malpractice happened to Saturday Night Live alumni, Dana Carvey. Two months after a double bypass surgery that was supposed to save his life, Carvey received news that his surgeon had bypassed one of the wrong arteries. The surgeon stated that the error was due to the unusual positioning of Carvey’s artery but the patient was unsatisfied and filed a lawsuit.

In a very dramatic case in 1995, in Florida, the wrong leg was amputated, although the patient was provided with compensation afterwards and the doctor’s license revoked.

3. Air embolisms

Although rare, air embolisms still occur more often than they should and pulmonary embolisms, are the leading cause of preventable deaths in hospital.

A case report published in the Journal of the Chinese Medical Association shared the tragic case of a 35-year-old female who, suffering from multiple abrasions from a car accident, was rushed to Accident and Emergency. The patient was given an endotracheal tube (intubation) but an error occurred when the patient’s oxygen flow meter was incorrectly connected to the tube.

Her face and neck began to swell immediately and her oxygen saturation dropped from 100% to 35-40% with no audible breathing. She was found to have air trapped in the layer under the skin and within the cavity outside the bowel. Apnea developed 10 minutes later. CT images revealed extensive air content within the extra-cranial and intra-cranial vessels including the carotid, vertebral and cortical arteries.
Ultimately, the patient died.

4. Wrong surgery

Wrong surgery is another sentinel event that occurs far more often than is acceptable. Last year, doctors in Tennessee, in America, operated on the wrong baby after “asking for the wrong infant” at a hospital. Jennifer Melton, gave birth to her son Nate at the University Medical Center in Nashville and told reporters that her son had undergone a frenectomy, to help with nursing problems - problems which he did not suffer from. In this case however, the doctor issued a public apology stating: “I had asked for the wrong infant. I had likely performed the procedure on an infant different than the one I intended to ... and I admitted my mistake and apologised.”

5. Blood transfusions

It is estimated that one in ten hospital stays where a medical procedure is performed will involve a blood transfusion. The most common mistakes made involving blood transfusions is that the wrong blood is given to the wrong patient or blood is incorrectly labeled when collected. Such was the case with 17-year-old girl Jésica Santillán. A heart and lung transplant was performed at Duke University Medical Center in North Carolina but doctors failed to check the compatibility of the donor’s blood type. A second transplant, meant to correct the error, caused complications, which resulted in Jésica being in coma. Brain damage and other complications caused her to die two weeks later.

Read more:
How criticising doctors can increase the risk of medical errors
GP in Singapore sentenced to prison for illicit sale of cough syrup
5 horrific breaches of trust by healthcare professionals

Sources:
https://psnet.ahrq.gov/primers/primer/18/wrong-site-wrong-procedure-and-wrong-patient-surgery
http://www.aaos.org/AAOSNow/2007/MarApr/clinical/clinical6/?ssopc=1
http://edition.cnn.com/2010/HEALTH/10/18/health.surgery.mixups.common/
http://www.nhs.uk/conditions/Air-embolism/Pages/Introduction.aspx
http://www.caringlawyers.com/blog/2011/02/13-disturbing-cases-of-medical-malpractice.shtml
http://listverse.com/2014/05/13/10-horrifying-medical-mistakes-that-could-happen-to-you/
http://www.independent.co.uk/news/world/americas/doctor-performs-surgery-on-wrong-baby-at-us-hospital-a6869046.html
www.nursingcenter.com/lnc/cearticle?tid=1111761
https://en.wikipedia.org/wiki/Sentinel_event
http://www.sciencedirect.com/science/article/pii/S1726490111000591
https://www.jointcommission.org