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An article in Saturday’s Boston Globe illustrated the gap that sometimes exists between written procedures and implementation. The article also highlighted the ongoing danger from surgeries on the wrong part of a patient’s body. Five hundred fifty-two cases of wrong-site surgery have been reported by American hospitals since 1995; there are undoubtedly many unreported cases.

The incident covered in the Globe story happened at Rhode Island Hospital. An 86 year old man was rushed into the operating room for emergency surgery to relieve a bleed on the left side of his brain. The surgeon operated on the right side, before correcting his mistake and addressing the left side bleed. The article did not reveal how much time was lost due to the doctor’s error, or whether the patient, who is hospitalized in stable condition, was permanently harmed. According to the Globe, this was the second time this year alone, that a neurosurgeon at Rhode Island Hospital has operated on the wrong side of the patient’s head.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has promulgated staightforward guidelines to prevent wrong-site surgeries. Even the best of guidelines are ineffective, however, if they are not followed. Patients with sufficient capability should be very insistent that protective steps have been taken to insure that once they are under anesthesia, the correct surgical procedure at the intended location, will take place.

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