A Massachusetts surgeon made headlines last week after performing arthroscopic surgery on an incorrect knee, leading some observers to wonder how wrong-site surgeries still occur even as staff and surgeons are aware of the importance - and ease - of avoiding such errors.

Heywood Hospital in Gardner, Mass., apologized for the error and is reviewing its policies and procedures to prevent similar incidents from happening in the future, according to a published report.

"It's ridiculous, with all the policies mandated by regulatory agencies, that wrong-site surgeries continue to be a problem," says Cathy Griswold, RN, MSN, CLNC, a legal nurse consultant and president of Health Care Educators & Consultants in Sykesville, Md. She discussed the issue of apologizing for surgical errors in the June issue of Outpatient Surgery Magazine.

The American Academy of Orthopaedic Surgeons says wrong-site surgery results from poor pre-operative planning, a lack of institutional controls, a failure of the surgeon to exercise due care or a simple mistake in communication between the patient and the surgeon. In its wrong-site surgery advisory statement, the AAOS emphasizes the importance of requiring the operating surgeon to sign the surgical site under patient supervision as well as confirming the surgical site during the pre-op timeout once the patient is in the OR. The organization recently introduced a series of posters designed to stress the surgical staff's diligence when following wrong-site surgery prevention standards.

Even the best safety precautions, however, will fail at the front line if they're ignored by staff and surgeons. "Policies are only as good as the healthcare providers that use them," says Ms. Griswold. "What I have seen in practice is complacency with procedures, nurses and doctors who do things so often that they are not fastidious in following the procedures that reduce the risk of errors."

Daniel Cook

A New Jersey woman is suing her orthopedic surgeon for invasion of privacy and battery after waking from spine surgery with a temporary tattoo of a red rose on her abdomen, below her panty line.

The surgeon, Steven Kirshner, MD, has applied tattoos to other patients as jokes to cheer them up post-operatively, says his attorney, Robert Agre, in a published report. "It was intended just to make the patient feel better," he explains.

But patient Elizabeth Mateo, who underwent surgery in April to treat a herniated disc, objected to Dr. Kirshner's bedside manner, especially since the tattoo is nowhere near the surgery site.

Since Ms. Mateo was positioned face down for the surgery, Dr. Kirshner had to lift up the front of her hospital gown - knowing that she was unclothed and under anesthesia - to apply the tattoo near her vagina, says the complaint Ms. Mateo filed with the Superior Court of New Jersey in Camden. As a result, it says, Ms. Mateo "continues to suffer mental and emotional anguish."

"She had no idea how it got there," says Ms. Mateo's attorney, Gregg Shivers, in a televised report.

The complaint does not name the hospital at which the surgery was performed, Virtua Health Memorial Burlington County in Mt. Holly, N.J., as a defendant. Virtua says it investigated the incident and determined that Dr. Kirshner applied the tattoo while no one was watching. Dr. Kirshner's attorney does not dispute that finding. "Clearly, he would not have acted in front of the entire operating room staff," says Mr. Agre in the televised report.

Kent Steinriede

In your efforts to reduce medical errors and adverse events, don't overlook one of the most valuable tools in your arsenal: your patients.

For a study published in the July 15 issue of the Annals of Internal Medicine, researchers conducted post-discharge interviews with nearly 1,000 patients from hospitals throughout Massachusetts in order to compare the patients' accounts of adverse events experienced during or after their hospital stays against the facilities' medical records. According to the study, about 23 percent of the patients said they experienced at least one adverse event, while the medical records of those patients' cases stated that only about 11 percent of them had experienced an adverse event.

"Our research demonstrates that patients themselves can be a valuable source of information about unexpected complications that occur as a result of medical care, both during their hospital stay and after they are discharged," says Joel Weissman, PhD, of the Massachusetts General Hospital Institute for Health Policy, in a press release.

Dr. Weissman identifies adverse events as "complications or injuries to patients - some of which may be due to preventable errors, and some of which are neither preventable nor error-related." In the study, 21 of the events identified in the patient interviews but not in the medical records were classified as serious and preventable.

The researchers recommend that hospitals and other healthcare organizations incorporate questions about patient safety into their post-discharge interviews and use those interviews in conjunction with medical records to track and prevent adverse events.

Irene Tsikitas