The slow progress is particularly disappointing in light of the increased awareness of errors and the promotion of specific steps to prevent them, Angood said.
The Joint Commission, for example, developed a protocol for preventing wrong-site surgeries, a category that includes operating on or removing the wrong limb or organ, doing the wrong procedure or treating the wrong patient.
For The Record
Los Angeles Times Thursday, March 06, 2008 Home Edition Main News Part A Page 2 National Desk 1 inches; 43 words Type of Material: Correction
Hospital errors: A headline in some editions of Saturday's California section said that a "wrong site" surgical procedure at St. Joseph Hospital in Orange was the third such mistake in just over a year; it was the third such mistake since January 2006.
Doctors are supposed to mark the spot they plan to cut in consultation with their patients before surgery. Nurses are supposed to call a "time out" in the operating room for a final check.
The approach acknowledges that humans make mistakes, so checks must be built into the system at various steps to catch them.
Safety experts agree that the protocol works -- when used. But a multitude of factors can interfere with its use, ranging from simple distractions found in any busy operating room to an entrenched culture in which some surgeons resent having to follow step-by-step instructions and some nurses are afraid to speak up.
The monitoring of protocols is also a factor, which St. Joseph Hospital learned in 1999 after a Tustin couple left the hospital with a baby who did not belong to them. The switch happened despite procedures put in place after three earlier mix-ups, including a mother breast-feeding the wrong infant. The hospital acknowledged that no one had checked to see whether nurses were following the new rules. It immediately announced an overhaul of maternity ward policies.
St. Joseph had adopted the Joint Commission's recommended protocol on wrong-site surgeries, Van Brunt wrote in an e-mail. She declined to give details about whether the internal investigations launched after each of the three incidents found common flaws. According to Casciari, the hospital has reinstituted a "top-to-bottom training program."
"Members of the clinical team involved in these cases have been deeply affected, and as a hospital we take this very seriously and regret that it happened," Casciari said.
Wrong-site surgeries are considered rare in the context of the number of surgeries performed each year. St. Joseph, for example, does about 25,000 surgeries a year, according to Van Brunt.
But just how rare they are is difficult to pinpoint.
About eight wrong-site surgeries are reported each month to the Joint Commission's voluntary reporting system, but they represent only the most serious cases, with 70% of them resulting in death.
