Oregon hospitals reported dozens of errors – some fatal – in both medical and surgical procedures in 2007, mostly because of faulty communication and procedure mistakes.
In a report released by the Oregon Patient Safety Commission, a branch of the state government that is required by law to release the statistics, the mistakes hospitals voluntarily reported totaled 83. Twenty-four of those were fatal.
Fifteen of the slip-ups reported involved doctors or surgeons failing to remove objects, usually surgical sponges, from patients after procedures.
Jim Dameron, the commission’s administrator, once attended a demonstration that made it much easier for him to see why such a mistake happens more often than any others.
“A surgeon filled a tank with Jell-O, put some sponges in there and made it so you couldn’t look in the sides,” Dameron said. “He said there were five sponges. I stuck my hand in the Jell-O and I rummaged around and found three sponges.”
In a typical surgical procedure, especially if it involves the midsection, the potentially dozens of surgical tools or sponges used can easily get lost, said University Health Center Medical Director Ben Douglas.

“It’s not like taking the top off a shoe box and just seeing everything at the same time,” Douglas said. “It actually can be a challenge to go back and review the place where you’ve been doing surgery.”
For that reason, some hospitals make sure two people count all the tools and sponges before and after a procedure to make sure nothing is missing at the end. When they fail to remove something from a patient, it probably means someone made a counting error.
Hospitals also reported a total of eight incidents in which doctors or surgeons performed procedures on the wrong body part.
“Humans are more or less bilaterally symmetrical, so it can happen,” Dameron said.
Another common and potentially fatal mistake many hospitals reported was the wrong prescription of medicine to patients, which Douglas said “has to do with communication” and rarely comes down to one person involved in treating a patient.
“There are places where errors can happen between patient and doctor, between the doctor and the operating room. If the medication is written wrong, then it’s the doctor’s responsibility. If the doctor writes the order and the nurse takes the paper and types it into a computer wrong, it’s the nurse’s fault. You just don’t know where it happened.”
Sometimes, Dameron said, none of the hospital’s employees is at fault.
“Another interesting wrinkle is, what’s the role of the patient?” he said. “Sometimes patients who don’t speak English say something wrong and confuse doctors.”
To lessen the chance for prescription errors, Sacred Heart Medical Center created a computerized system connected to its pill dispenser. If doctors and nurses type in the prescription drug correctly, the drug dispensed into the patient’s container is guaranteed to be the correct prescription.
Hospitals reported only 10 medication errors, but Dameron predicted the errors were underreported, which he says is one of the “minuses” of the state’s voluntary reporting system. Oregon is the only state in the U.S. that has a voluntary system; all other states require their hospitals to report errors.
However, Dameron said, there are both pros and cons that come with the two systems.
“Even mandatory systems suffer from the same issues, like whether hospitals are underreporting,” said Dameron. “Waving a magic wand doesn’t make them go away.”
[email protected]