Wrong Leg Amputation Focuses Attention on Surgical Errors and other Medical Mistakes

When an Austrian man had the wrong leg amputated this month, journalists and researchers took a look at medical mistakes, which were thought to be the third leading cause of death in the U.S. prior to 2020.

“Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital.  The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures.

The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period.  It was recognized during a routine wound dressing change, about 48 hours postoperatively.

“A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said.  “We would also like to affirm that we will be doing everything to unravel the case, to investigate all internal processes and critically analyze them. Any necessary steps will immediately be taken.”

Surgical errors are a common problem in the U.S., with approximately 4,000 or more mistakes occurring each year.  Sentinel events are unexpected events that result in a patient’s death or a serious physical or psychological injury.  In 2018, of 801 sentinel events that were voluntarily self-reported by accredited or certified organizations, there were 111 reports of unintended retained foreign bodies in surgical patients, and 94 reports of wrong site surgery.  Further, according to an article in Hand that was published in 2012, wrong site surgery is estimated to occur 40 times per week in hospitals and clinics in the U.S.   A study published in Spine in 2008 revealed that of the 415 neurosurgeons who took the time to complete the study’s survey, 50% (207) reported performing a wrong level surgery at least once during their career.

A 2008 article in Surgery that assessed underlying errors contributing to surgical complications over a 12 month period in a  department of surgery revealed that of 9,830 surgical procedures, surgical error resulted in 41 deaths.  Sometimes, injuries and deaths in the OR occur from “non-surgical” incidents.  From 2000 – 2017, in a query of cases in the American Society of Anesthesiologists Closed Claims Project, it was revealed that 21 patients had fallen off of an O.R. or procedure table.  Between 1985 and 2013, there were 103 fires in the O.R. that injured patients, causing claims to be filed.

Mistakes in the OR are just a portion of medical errors that occur each year in the U.S.  Over the last several years, medical mistakes were thought to be the third leading cause of death in the U.S., behind heart disease and cancer.  (Currently, Covid-19 is thought the be the third leading cause of death.)

A 2013 study revealed one sixth of all deaths in the U.S. were caused by hospital mistakes.  According to a report published in the Journal of Patient Safety, hospital errors were responsible for approximately 440,000 deaths annually.  Further, research has shown that 10 –20 times that many people suffer very serious, non-deadly injury caused by medical errors.

HOW TO STAY SAFE IN A HOSPITAL

Some steps that patients can take to help prevent medical error include:

1. Obtain second and third opinions regarding your medical conditions and recommended management / treatment options;
2. Write down the names of all caregivers;
3. Keep a journal of your medical care, including what is being done, what is being proposed, and what the treatment alternatives are (including risks and benefits);
4. Have a patient sitter with you in the hospital;
5. Ask questions and courteously demand answers;
6. Bring a voice recorder, camera or phone to the hospital and clinic visits;
7. Take steps to verify you are given correct medication;
8. Be aware of when errors are likely to occur (on weekends, nights, holidays, during staff shortages, and in July when new residents start);
9. Review your medical records.