When Hospitals Skip the Checklist, Patients Pay the Price
Every year in the United States, tens of thousands of patients are harmed by preventable surgical errors. Wrong-site surgery. Wrong-patient procedures. Surgical instruments left inside the body. Infections from failures in sterile technique. Complications from inadequate pre-operative planning.
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Article written by Brendan Lupetin, Esq. Brendan is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
What makes these errors so difficult to accept is that they are not mysteries. They are not the product of unforeseeable complications or the irreducible complexity of medicine. They are failures of process — breakdowns in the systematic, verifiable steps that hospitals and surgical teams are required to follow to keep patients safe.
The WHO Surgical Safety Checklist has been validated in hospitals across the world. The evidence that it prevents deaths and serious complications is unambiguous. Pennsylvania hospitals and surgical teams that fail to implement and follow it — and patients who are harmed as a result — have a legitimate basis for a medical malpractice claim.
What the WHO Surgical Safety Checklist Requires
In 2008, the World Health Organization launched its Safe Surgery Saves Lives program and introduced a surgical safety checklist now used in hospitals in more than 160 countries. A landmark study published in the New England Journal of Medicine in 2009 evaluated the checklist across eight hospitals in eight cities — from Seattle to New Delhi — and found that death rates fell by nearly half and major surgical complications dropped by more than a third at every participating hospital.
The checklist is organized around three critical moments in every surgical procedure:
- Sign In (before anesthesia): Verification of the patient’s identity, the surgical site, the procedure to be performed, and the patient’s consent. Confirmation that the site has been marked, that the anesthesia machine and medications have been checked, and that the patient’s allergy and airway status are known.
- Time Out (before the incision): A pause in which every member of the surgical team — surgeon, anesthesiologist, nurses, and technicians — verbally confirms the patient’s identity, the procedure, the surgical site, and the team’s anticipated critical events. Confirmation that prophylactic antibiotics have been administered, that essential imaging is displayed, and that sterility of instruments has been confirmed.
- Sign Out (before the patient leaves the operating room): Confirmation of what procedure was performed, that the instrument and sponge counts are correct, that specimens are properly labeled, and that key concerns for the patient’s recovery have been communicated.
None of these steps involves new technology. All of them involve doing — systematically and verifiably — what a careful surgical team should be doing anyway. The evidence shows that in the real world of busy operating rooms, human memory alone is not sufficient. The checklist is.
The Most Common Preventable Surgical Errors
When surgical safety protocols break down, the consequences range from serious to fatal. The types of surgical errors we most commonly investigate in Pennsylvania include:
- Wrong-site surgery: Operating on the wrong knee, the wrong side of the spine, the wrong hand. These are considered “never events” — errors that should never occur when proper verification protocols are followed. They continue to occur at an estimated rate of 40 times per week in the United States.
- Wrong-patient procedures: Performing a surgery on the wrong patient — a failure of the identity verification step that the surgical time-out is specifically designed to prevent.
- Retained surgical instruments: Sponges, clamps, needles, and other instruments left inside patients after surgery. These should be caught by the Sign Out count requirement. When the count is not done correctly — or not done at all — patients are harmed.
- Surgical site infections: Infections resulting from failures in pre-operative skin preparation, sterile draping, antibiotic prophylaxis, or instrument sterilization. All of these are addressed in the WHO checklist.
- Anesthesia errors: Administration of the wrong medication, wrong dose, or failure to account for known drug allergies — failures that pre-operative verification is designed to catch.
- Failure to address intraoperative emergencies: Surgical teams that have not completed the Time Out briefing are less prepared to respond to unexpected critical events, including hemorrhage or cardiopulmonary complications.
The Legal Standard: Hospitals Are Responsible for Their Systems
Pennsylvania hospitals are required by accreditation standards, patient safety law, and the common law standard of care to implement and follow evidence-based surgical safety protocols. The Joint Commission — the accreditation body for most Pennsylvania hospitals — has required a Universal Protocol, including the surgical time-out, since 2004.
When a hospital’s surgical safety system fails — because the time-out was not completed, because the site verification was skipped, because the sponge count was not done — and a patient is harmed, the hospital bears institutional responsibility for that failure. Individual surgeons and anesthesiologists may also bear personal liability depending on their role in the failure.
Pennsylvania law recognizes that patients have a right to expect that the hospital operating room is governed by rational, evidence-based systems of care — not by the hope that everyone will remember everything without any structured verification. When those systems fail, injured patients have legal recourse.
What to Do If You Believe a Surgical Error Harmed You
Surgical errors are not always immediately apparent. A retained instrument may not cause symptoms for weeks or months. A wrong-site surgery may not be discovered until a follow-up imaging study reveals that the wrong structure was operated on. An infection may not manifest until after discharge. Here is what to do if you suspect a surgical error:
- Request a complete copy of the operative report, the anesthesia record, and all nursing documentation from the surgery. These records will show whether the time-out was documented and what the surgical team performed.
- Request copies of all post-operative imaging studies if you had any — X-rays or CT scans taken after surgery that might reveal retained instruments or other complications.
- Do not sign any documents presented by the hospital’s risk management or patient relations department before consulting an attorney.
- Act promptly. Pennsylvania’s statute of limitations for medical malpractice is generally two years from the date of the injury.
About Lupetin & Unatin, LLC
Lupetin & Unatin is a boutique medical malpractice and catastrophic injury firm based in Pittsburgh, Pennsylvania. We represent patients harmed by surgical errors, retained instruments, wrong-site surgery, post-surgical infections, and anesthesia complications throughout Pennsylvania. Our attorneys are Fellows of the American College of Trial Lawyers and have been recognized by Super Lawyers and Best Lawyers in America. All cases are handled on a contingency fee basis — no fee unless we win.
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If you or a family member suffered a serious complication from surgery in Pennsylvania and you have questions about whether the surgical team followed proper safety protocols, contact us today. There is no cost and no obligation for an initial evaluation. Call (412) 281-4100.