Time out: Health system in Iowa has 4 wrong-site surgeries in 40 days

In the span of 40 days last fall, surgical teams from Genesis Health System based in Davenport, Iowa, performed four wrong-site surgeries, according to an investigative report by KWQC.

 

On Oct. 23, 2015, a surgeon from Genesis West in Davenport sliced into the left hip of an octogenarian patient. The patient was there for surgery on a broken right hip.

On Nov. 5, a physician at Genesis East, one of the health system's two Davenport hospitals, mistakenly ordered the wrong half of patient's thyroid removed. The surgical team realized the error after the operation, and reopened the patient's neck to remove the right side of the thyroid. That side of the gland was cancerous, and because cancer was found, standard procedure would have called for another surgery to remove the rest of the thyroid.

Ken Croken, Genesis' vice president of corporate communications, did not provide KWQC with details of the other two wrong-site surgeries, but did say they were not serious safety events.

"The severity of the error is critical to understand, in the case of these four errors, no serious consequence reached the patient, relatively speaking," Mr. Croken told KWQC.

In a staff memo, Genesis asserted that the crux of these mishaps was due to the improper execution of time outs, when the operating team is supposed to double check the patient, the procedure and the site prior to incisions. These moments of pause were found to be infiltrated by distractions like music playing in the background. Markings on the patients were also sometimes not visible, and in one instance, the Iowa Department of Inspections and Affairs no written evidence to confirm that a time out occurred, though Mr. Croken asserts that it did.

The IDIA also found that in the wake of these incidents, Genesis failed to immediately implement a system to ensure time outs were being properly executed.

Genesis submitted a plan of corrections to the IDIA. It was confirmed as effective. After a follow-up inspection in early February, it was determined that Genesis was back in compliance with federal regulations. Additionally, Mr. Croken said members of a team involved in a wrong-site surgery were going through a disciplinary process.

"It's our philosophy here and again it has earned us national recognition, safety is the most important of all of our objectives," Mr. Croken said, according to KWQC.

Note: The headline of this story has been changed to avoid confusion.

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