Their fix sounds like its a reaction to some specific instances which is good it will improve things but its hardly a fix. they touch on it briefly that the previous solution wasn't working because " In effect, this protocol asks busy health-care staff to slow down, be more careful — which would be a great idea, if it worked." the biggest improvement for this error and others would be putting less pressure on medical staff to rush. I cant see that ever happening though. In the i.t. industry we know that to reduce failure you need as independent as possible redundancy and checks. in i would think in the case of surgery it could mean 2 qualified people to mark the location without being influenced by the other and referencing different sources. eg if its something like an eye and the condition can be noticed by examination one would physically examine and mark with a uv marker the other references a medical record or surgery form and marks, then they shine a uv light on the person and verify that they both marked the same location. ideally the mark should be how the initial cut would be made and different color for each person verifying. and it should be visible at the time of making the cut otherwise your introducing a single point of failure. if there is a situation where there is no area to mark there could be some sort of mask and how its written on the mask that they could mark on and then just before you cut you lift off the section that is being cut. it would have to be a mask that would be very obvious if it was out of position.
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Chassin gets it exactly backward. In 2011, a doctor in Oregon performed surgery to correct a 4-year-old boy’s wandering right eye, but the surgeon erroneously operated on the child’s left eye. Before this surgery, the correct operative site had been marked in accordance with the Universal Protocol, but when a nurse prepped the wrong eye for surgery, the surgical drapes covered the marking — the very problem that Chassin thinks will affect negative labeling. But if a negative label had been placed on the boy’s left eye, then that warning would have been exposed when the nurse prepped the wrong eye. If the negative label were obscured by surgical drapes, that would mean the correct side had been prepped.
I also wonder if the list creators have considered wrong body part surgeries as particularly problematic. Hard to tell from the checklist.
Over 38 years working full time as an anesthesiologist – 18 years in academic medical centers (UCLA and the University of Virginia), the rest in private practice — on average I knew of about 1 case/year. I'm sure there were many more.