Errors in the OR: Massachusetts lawmaker proposes videotaping surgeries

Kevin Lyons

In 2010, more than 800 medical mistakes – such as operating on the wrong body part or leaving a surgical tool inside a body – were reported to a nonprofit group that accredits more than 19,000 health care organizations in the United States.

To help avoid such errors, a state lawmaker wants to give patients in Massachusetts the right to have video recordings of their surgeries done at their own expense.

A bill authored by Massachusetts state Rep. Martin Walsh, a Democrat from Dorchester, would enable someone to have a surgery videotaped — letting a patient, their loved ones or others see what happened in the operating room. A hospital refusing to allow recordings would be fined $10,000.

“I wrote the bill because a constituent lost his mother in the operating room and felt he never got a full answer as to why she passed away,” Walsh tells InsuranceQuotes.com.

No state has such a law on the books. In an isolated case in 2009, the Rhode Island Department of Health ordered Rhode Island Hospital to install cameras in operating rooms after finding that the Providence hospital performed five wrong-site surgeries in two years.

‘Wrong site’ surgeries

The number of medical mistakes and “wrong site” surgeries has become so troubling that the nonprofit Joint Commission Center for Transforming Healthcare organized a team of medical professionals to study the issue and devise ways to stop what industry leaders call “never events” — events that they say should never happen at health care facilities.

“While wrong-site surgery is not an everyday occurrence, all facilities and physicians who perform invasive procedures are at some degree of risk,” says Mark Chassin, president of The Joint Commission.

The commission, which is the country’s premier accrediting organization for health care providers, estimates that as many as 40 wrong-site procedures happen each week across the country.

Chassin and eight other medical professionals outlined solutions to wrong-site surgeries during a conference call June 29. They all reported discovering that problems with scheduling, mix-ups in the pre-operating room, shoddy communication and distractions in the operating room were among the factors that boosted the risks of wrong-site surgery.

“In a couple of places, we found unapproved pens were being used to mark the (surgery) site and the mark washed away. … That’s something very simple, but important,” Chassin says.

One of the professionals working on Chassin’s team heads Lifespan Corp. in Rhode Island, which oversees Rhode Island Hospital. Mary Reich Cooper, senior vice president of Lifespan, says cameras in the operating rooms at Rhode Island Hospital record surgeries just twice a year; officials use the footage to seek ways to improve identification of parts of the body where surgical incisions are supposed to happen.

However, Cooper says, the hospital made improvements primarily through more intense training and self-policing. The hospital hasn’t recorded a wrong-site surgery since 2009, she says.

Bill faces a tough road

Walsh acknowledges his camera legislation in Massachusetts will be tough to pass. During a June 14 hearing, the Massachusetts Medical Society and the Massachusetts Hospital Association testified against it. Walsh wrote a similar bill in 2007 that never reached the House floor for a vote.

Walsh says the biggest concern is cost: Who’s going to pay for the video equipment?

Chassin of The Joint Commission says cameras in the operating room would not be a cure-all, since errors that occur outside the operating room most often contribute to wrong-site surgeries. “Cameras can’t observe the entire process,” Chassin says.

Cooper says she doesn’t support the Massachusetts measure.

“Even though the (Rhode Island Hospital) staff has been comfortable with the cameras in place, we would not encourage using them the way they are used in the casinos as an ‘eye in the sky,’” Cooper says.