In 2004, the Joint Commission -- the organization that accredits American hospitals -- rolled out mandatory rules focused on preventing surgical errors in operating rooms across the country. They were deemed simple and straightforward, and centrally encompassed the following: Verify the patient; mark the site where surgery is to be performed; and call a quick group timeout, that includes the surgeon, to clarify what the surgery is about and what is to be expected.

Looking back from the present, The Commission and many doctors and researchers across the country believe that things have not gotten better over the past handful of years regarding "never events" -- things that should simply never occur in surgery, such as operating on the wrong patient or body part. In fact, the Commission estimates that wrong-site surgery occurs about 40 times every single week in U.S. hospitals.

What is the problem? Why aren't things getting better, especially with the strong focus on improving medical error and reducing harm that is evidenced by programs such as the government's Partnership for Patients program (see our June 16 blog post) and heightened scrutiny by Medicare and Medicaid officials concerning errors?

Mark Chassin, the president of the Joint Commission, thinks that a key factor may be doctors and surgeons who prize their central roles in the medical process, resist new requirements on principle and even find it offensive to be required to participate in pre-operative group sessions. A director at the Johns Hopkins Center, Peter Pronovost, says that doctors often pay mere lip service to the rules and engage in "ritualized compliance."

That may be changing, with high-value malpractice suits and developments such as Medicare simply not paying for wrong-site surgeries. Hospital administrators are under increasing pressures, and may begin leaning more heavily on their surgeons to conform to the new norms.

Related Resource: Kaiser Health News, "Effort to End Surgeries on Wrong Patient or Body Part Falters" June 20, 2011