Reporter documents surgical errors through public records

By Lizbeth Kowalczyk
The Boston Globe

I was working on a story in September about the cost of medical errors, when I discovered some data that shocked me.

In one year, Minnesota hospitals had operated on the wrong part of a patient's body 23 times and left sponges and other objects inside surgery patients 42 times, they reported to the state health department.

I was shocked because hospitals were supposed to have solved these problems long ago. More than 10 years ago, during my first year as a medical reporter at The Patriot Ledger in Quincy, Mass., I had written a story about two surgeons who took out a patient's right kidney instead of her cancerous left kidney. This and other high-profile cases prompted many hospitals at the time to require "time outs" before operations to verify the patient's name and the procedure, and to mark the correct spot with an "X."

If I could find out how many surgical mistakes occur in Massachusetts, I thought that might make a good story. Unlike Minnesota, most states do not publish this type of data. But reporters generally can get it through the Freedom of Information Act. Hospitals are required to report serious incidents to state officials — in Massachusetts, the public health department — and these reports are public in some form.

I asked the health department to run a computer search of the report and investigation summaries for 2005, 2006 and 2007-to-date for the phrases "retained object," "wrong site," "wrong side," "wrong patient" and "wrong procedure." I always ask for summaries first, because the department provides these more quickly, and then I ask for full investigation reports for the cases that interest me.

Health officials found 36 cases of surgery that involved the wrong site, wrong patient or wrong procedure, and 38 instances of objects left inside patients. Descriptions of incidents showed that procedures such as time-outs were not implemented consistently and that surgeons in particular sometimes didn't follow them. In some instances, nurses and technicians didn't confront surgeons about lapses, even though they acknowledged later that they knew the surgeon was cutting into the wrong knee, for example.

I found officials at the Minnesota health department very helpful; they've analyzed these problems carefully and talked about the most common reasons they still occur.

The reports I received from Massachusetts officials were redacted, meaning patients' names and many details about illnesses and procedures had been whited-out. But the reports included where the incidents happened, so I could tell which hospitals had multiple errors and could interview hospital executives and doctors to get more information about cases. I have found that hospitals are more eager to talk about state investigations if I explain that I want to know about improvements they've made since the error occurred.

Also, because of an agreement with Medicare, whenever Massachusetts health officials find "deficiencies" at a hospital while investigating an incident, the so-called "Statement of Deficiencies" is not redacted and contains good information.

While 74 surgical errors is a small fraction of the thousands of operations done in Massachusetts each year, I still think the number is significant. These types of problems should always be preventable through vigilance by staff and good procedures, and if hospitals can't get this right, how can they hope to stop more complicated problems like infections?

Experts I interviewed agreed. The Joint Commission, which accredits U.S. hospitals, had a conference on wrong-site surgery in February, during which officials expressed disappointment over the persistence of these mistakes.

The Globe ran the story on page 1.

In these 74 cases, no patient died as a result of an error. But I have used the health department reports to find families of deceased patients for other stories — even though the reports don't include names.

When a patient has died at a particular hospital on a certain date, I have called or visited the clerk's office in the town or city where the hospital is located. I have looked up the death certificate by date and place of death to find the patient's name. I've then tracked down family members using online people finders or just directory assistance.

Also, if a hospital says a case is the subject of a lawsuit, ask for the name of the lawyer for the patient or family. Patients and families can get unredacted copies of state investigation reports, and many lawyers will provide these.

Lizbeth Kowalczyk is a medical/health care writer at The Boston Globe.