My lede:

Performing surgery on the wrong body part — or, worse yet, the wrong patient — is the kind of mistake physicians agree should never happen.

A series of reports from hospitals documenting how these devastating errors slip through the cracks prompted the Joint Commission in 2004 to mandate a three-step protocol. It required physicians and other health professionals to perform a pre-procedure verification process, mark the correct site for the procedure and conduct a “timeout” discussion as a final check before the procedure begins.

Yet new evidence shows the commission’s “universal protocol” has not stopped wrong procedures.

In fact, the number of wrong-patient and wrong-site procedure reports rose, according to a study of more than 27,370 adverse events self-reported by Colorado physicians and published in the October Archives of Surgery. The study found that 132 wrong-patient and wrong-site procedures were voluntarily reported to the Colorado Physician Insurance Co. from 2002 to 2008, with peak annual numbers of reports for both categories occurring after the commission’s protocol was required.

Read the whole shebang.