Pennsylvania hospitals adopt safeguards against preventable surgical errors

Anna Mazur could hardly see out of her left eye because of a blocked vein and mounting pressure from glaucoma.

But when she went to the University of Pennsylvania's Scheie Eye Institute for surgery in March 2011, surgeons operated on her relatively healthy right eye instead.

There were complications, and, according to a specialist retained by her attorney, she became legally blind as a result.

The hospital declined to comment, citing a lawsuit filed on Mazur's behalf, but the mistake illustrates how in an age of presurgical checklists, enhanced training, and other preventive measures, even a prominent medical center still can be the site of what the health-care industry calls "never" events.

Mazur, 92, said her vision was so bad after the surgery that she could no longer live on her own in Port Richmond. She now splits her time between her daughters' homes in Marlton and Bridgeville, Del. - unable to read, watch videos of her great-grandchildren, or fix her own meals.

"I was in good health and did everything myself," she said. "Now I just have to sit and wait and see what happens to me."

Pennsylvania is known for its efforts to reduce the number of surgeries performed on the wrong site or wrong patient. Twenty such surgeries were reported in the state during the first half of this year, according to the Pennsylvania Patient Safety Authority, a state agency charged with reducing medical errors. The total for the 2011-12 academic year was 47 - the lowest 12-month figure since the agency started collecting data in 2004, and well below the average of 63.

Still, at a rate of about one such mistake per 100,000 procedures, that is not good enough, said John R. Clarke, the authority's clinical director and a professor of surgery at Drexel University.

"It should be, to quote my mother, as rare as hens' teeth," Clarke said.

Yet the trend is promising, as the improvements have generally occurred in hospitals that have adopted a series of best practices proved to reduce error, Clarke wrote in a March advisory for the authority. At the time, 49 facilities had collaborated with the authority on such an effort, nine others had done so on their own, and both groups reported steady declines.

One group collaboration took place with the help of the nonprofit Health Care Improvement Foundation. Such programs take many months to implement because they involve intense education and often require a change in operating-room attitudes and culture, Clarke said.

The hospitals adopt 21 principles established by the Patient Safety Authority, many of which sound like common sense but which nevertheless are the kinds of things that get lost in a busy hospital environment unless they are spelled out.

They include: specifying the correct site when the procedure is scheduled, asking the patient to identify the site, physically marking the site on the patient, and holding a presurgery "timeout" in the operating room so all parties present can confer to ensure that the operation proceeds correctly.

Officials at Penn declined to say whether it had been among the hospitals to undertake improvement plans, citing the Mazur litigation, which was filed in June in the Court of Common Pleas by lawyer Michael A. Ferrara Jr.

Penn's Scheie Eye Institute is a leading research center where doctors developed a groundbreaking gene therapy that has improved the vision of patients with a rare form of blindness.

Ferrara said he had yet to receive a complete account of how the mistake in Mazur's case happened. The operative report states that "the right eye was confirmed to be the operative eye and was marked," according to a review by New Jersey ophthalmologist Joel Confino, whom Ferrara retained. "Perioperative notes" state that the site was identified by a nurse and verified by Eydie Miller-Ellis, who performed the surgery, according to the review.

According to her bio on Penn's website, Miller-Ellis is director of the glaucoma service at Scheie, as well as at the Philadelphia VA Medical Center.

Mazur's procedure was called a trabeculectomy, in which the surgeon cuts a small hole in the eye to relieve excess pressure, then covers it with a flap of tissue.

In Mazur's right eye, however, the pressure was stable and not in need of correction, according to her complaint.

After the surgery, the pressure in her right eye dipped to zero, and her vision worsened as a result, the complaint states. A loss of pressure can impair vision in a number of ways, among them by causing folds in the retina.

Upset by the mistake, Mazur switched to Wills Eye Institute the next month for surgery to relieve pressure in her left eye - the one that was supposed to have been operated on in the first place. The operation lowered the pressure, but her vision in that eye has not improved. Using the left eye, she can see when someone waves a hand in her face, but no more, said her daughter Eileen Zaharchak.

Mazur later went back for surgery to remove a cataract in her right eye, which helped somewhat, Zaharchak said. But vision in the right eye has since declined again. With that eye, Mazur can see letters on a Kindle electronic reading device if they are enlarged so that there are just a few words on the page, her daughter said.

Yet Mazur said reading was too difficult.

"The letters keep on floating," she said.