Sacred Heart reports mistakes
A backward X-ray and a misidentified spinal surgery site contributed to Sacred Heart Medical Center surgeons operating on the wrong body parts twice last spring.
The Spokane hospital logged mistaken surgeries on March 5 and May 7, according to records of adverse events reported to the state Department of Health.
Dr. Jeff Collins, Sacred Heart’s chief medical officer, said both incidents were “relatively minor” and were corrected quickly with no ill effects on patients.
The operations were among 20 surgeries performed on the wrong body parts statewide during the first year of a law that requires Washington hospitals to publicly report 27 serious mistakes. Through the end of June, hospitals also reported 83 incidents of severe, life-threatening pressure ulcers and 31 instances of objects being left behind after surgery, records showed.
Sacred Heart logged the most serious recent incidents among local hospitals. On March 5, an X-ray was placed backward onto a viewer, causing a surgeon to operate on the wrong part, Collins said.
Collins refused to identify the procedure or the body parts, saying that that could potentially identify the patient. He characterized the incident as a “left-right discrepancy.”
“The correct side was addressed, and there was no harm done,” Collins said.
The second mistake, on May 7, occurred when a surgeon operated on the wrong level of a patient’s spine, Collins said. The doctor recognized and corrected the mistake during the procedure, Collins said.
“Imagine you were sewing on a button,” he said. “It’s as if you put the needle through the upper right-hand hole instead of the upper left-hand hole.”
The mistakes led surgery teams to review their procedures, he said. A new policy calls for X-rays to be performed and reviewed in the operating room at the time of the surgery.
The hospital has a detailed process to prevent wrong-site operations, Collins said. Patients sign consent forms and surgeons physically mark the correct site. The entire surgical team takes a “time-out” to review the operation before going ahead, he said.
Although those practices were followed in the March incident, the backward X-ray led to the mistake. Collins said he didn’t recall the new policies regarding X-ray placement.
The new law has had minimal impact on hospital practice, Collins said.
“I don’t think it’s changed our procedures much at all, except for additional paperwork,” he said.
He cautioned that patients can’t rely solely on adverse event notices to choose a hospital.
“It gives patients one measure of one aspect of a very complicated process,” said Collins, who questions whether the reporting law is helpful.
“I don’t know that it is,” he added.
Hospitals aren’t disciplined for the mistakes they make, said Byron Plan, a manager in the state Health Care Survey office. State officials are compiling information to detect correctable patterns, he said.
Records also showed Sacred Heart surgeons left an object behind after surgery on March 6, but Collins said that’s a mistake in the records that health officials have failed to correct. Linda Furkay, the state’s adverse event specialist, did not immediately return a call about the mistake Tuesday.
Since a Feb. 7 Spokesman-Review report, Deaconess Medical Center in Spokane logged at least one incident of severe pressure ulcers Feb. 23. The records list two incidents on that date, but it’s not clear whether it’s a duplicate report. Coulee Community Hospital in Grand Coulee also reported an instance of severe pressure ulcers June 25.