Using the Universal Protocol to Avoid Medical Errors in California

California Medical Malpractice News

In September 2011, the California Department of Public Health (CDPH) announced administrative penalties against 12 California hospitals for failure to meet licensing requirements that the CDPH determined caused or was likely to cause serious injury or death to patients.

When these failures occur, a patient who suffered serious harm as a result may be able to make a claim against the at-fault health-care provider in a medical malpractice lawsuit.

Kaiser Fined for Wrong Lens Implant in Cataract Surgery

Kaiser Foundation Hospital & Rehabilitation Center in Vallejo, California, was one of the hospitals fined $50,000 for dangerous practices. The CDPH reported that the hospital failed to ensure the health and safety of a patient when it did not follow its surgical policies and procedures, resulting in a patient receiving the wrong lens implant in cataract surgery.

The patient’s wife, who has the same last name, was scheduled for cataract surgery with the same surgeon in the next month, and the doctor mistakenly implanted a lens with her measurements in the patient’s eye instead of a lens with his measurements, according to CDPH documents. As a result of the negligence on the part of Kaiser, the patient had to undergo surgery a second time to remove the wrong lens and implant the correct lens, which – in addition to the risks inherent to eye surgery – increased his risk of surgical complications like infection, discomfort and extended healing time.

The Universal Protocol

To prevent these types of medical errors from occurring, the Joint Commission, the main medical-licensing body in the U.S., developed the Universal Protocol. The Universal Protocol for Preventing Wrong Site, Wrong Procedure and

Wrong Person Surgery was created in 2003 and updated in 2010 “to address the continuing occurrence” of these avoidable medical errors in all accredited hospitals, ambulatory care centers and office-based surgery facilities. The three main components of the Universal Protocol are:

  • Pre-procedure verification;
  • Surgical site marking;
  • A time out immediately before beginning the procedure.

According to Stanford Medical Center, pre-procedure verification requires that all documents, including two patient identifiers (such as name, birth date or medical record number), be checked and any discrepancies resolved before the procedure begins. Also before the procedure starts, the surgical site should be marked and verified, involving the patient if possible. Site marks should be made so they are visible after cleaning and preparing the surgical site.

Last, the Universal Protocol declares that a final time out should be taken immediately before the procedure to finally verify that the patient, procedure, site, side and any implants or equipment are correct.

In an analysis of wrong-lens implants, wrong-eye cataract surgeries and wrong-patient cataract surgeries, a study reported by the American Academy of Ophthalmology found that following the Universal Protocol would have prevented the medical error in 85 percent of the cases studied. Wrong-lens implantation was the most common error, representing 63 percent of the 106 incidents reviewed.

The study authors also emphasized that, while wrong-lens implantation and other errors in cataract surgery are relatively rare considering the frequency of the operations, the consequences of an error can be serious for both the patient and the doctor.

Medical Malpractice Liability for Avoidable Medical Errors

If the Universal Protocol or a hospital or clinic’s procedures are not followed, and a patient suffers harm as a result, the patient may be pursue a medical negligence claim against the health-care providers that failed to follow proper procedures. In addition, if a hospital or clinic follows its procedures but they do not reflect appropriate standards of care, and a medical error or patient harm results, the health-care providers and organization similarly may be held liable for the harm caused.

Through a medical malpractice lawsuit, a patient may be able to hold a health-care provider accountable for an avoidable medical error and instigate change in the organization to improve its error-prevention measures. In addition, a patient may seek monetary compensation, called damages, for the negative consequences of the error such as:

  • Pain and suffering
  • Physical impairment and disfigurement
  • Past and future medical expenses
  • Lost wages and reduced earning capacity

If you or a loved one suffered harm from a medical error at a hospital or clinic, contact a knowledgeable attorney with experience in medical malpractice cases. Certain restrictions limit the amount of time you have to file a claim, so it is important to seek legal advice as soon as possible.