Before a medical procedure, find ask about the procedure for preventing errors.

RODALE NEWS, EMMAUS, PA—You enter a hospital trusting that the medical professionals know what they’re doing. But an analysis of a Colorado malpractice claims database found that even after years of efforts to improve the quality of care, doctors are still making serious mistakes, including operating on the wrong patient or the wrong part of the body.

THE DETAILS: Researchers analyzed a database that contained more than 27,000 reports from 6,000 physicians of medical errors or near misses that occurred between 2002 and 2008. The researchers found that 107 procedures (surgical and nonsurgical) were performed on the wrong site, and 25 were on the wrong patient. The most common reason for the wrong-site procedures was errors in judgment, while errors in communication were responsible for the wrong-patient procedures. For instance, three patients had their prostates removed because their biopsy samples were mislabeled.

“It’s shocking that such errors still occur,” says Philip F. Stahel, MD, director of orthopedic surgery at Denver Health Medical Center, who directed the study. That’s because something called the Universal Protocol, a series of steps designed to prevent exactly the kind of mistakes Stahel’s study found, was instituted at hospitals throughout the country in 2004.

The protocol requires that the correct procedure for the correct patient at the correct site be verified before the procedure begins; that the procedure site be marked; and that a time-out occur just before the procedure or incision to make sure all questions and concerns are addressed.

Yet, the majority of the errors Dr. Stahel and his colleagues found occurred three years after the Universal Protocol was instituted.

The reason? Stahel suggests that maybe doctors go on autopilot when they perform the protocol steps, and don’t think about each individual step and its implications. Other possibilities are that they “assign” the steps to assistants; nurses and others in the operating room don’t feel empowered to intervene when they have a concern; and doctors resist calling the required time-out.