Wrong sided surgery continues

Even with “time outs” wrong sided surgery continues to occur as this summary abstracted from an article in the Providence Journal (9/22/08) indicates: A doctor at the XXX Hospital operated on the wrong knee of a patient undergoing elective surgery. The surgical team had apparently followed the key safety protocols, including marking the correct knee and pausing to verify the site before operating -- but somehow still made the error, according to the hospital president and chief executive officer.   The mistake was first noticed by the patient when she regained consciousness. The hospital then performed the surgery on the correct knee, and the patient is doing well the hospital president said.

 

According to the hospital president's account, the surgeon marked the correct knee with the word "yes." Even so, the wrong knee was mistakenly draped for surgery. Then, in the operating room, the team took a "time out" before surgery to verify that they were about to do the correct surgery on the correct site.  "That was done by six people," the hospital president said. "They all agreed that they had the proper side ready. ... They knew the surgery was supposed to be on the left side. Somehow the system didn't work the way it should."

 

David S. Smith, M.D., Ph.D.

Comments

[David E. Longnecker]

I attended the Wrong Surgery Summit II (wrong surgery includes wrong side, wrong patient, wrong procedure), hosted by the (then) JCAHO. Two impressive points flowed from that conference:
1) covert observation revealed that team members did not give their undivided attention to the "time out". Surgeons were looking at x-rays, circulating nurses were gathering equipment, scrub nurses/techs were arranging the instruments, anesthesiologists were filling in their records. In short, the time out was considered a routine task, one that was riddled by what safety experts call secondary task intrusion. Multi-tasking leads to errors in all environments, whether it is driving an automobile or preventing errors in ORs.
2) "wrong procedure" errors were being reported with increasing frequency for anesthesia procedures, especially because the Universal Protocol was not followed for peripheral nerve blocks, etc.; this led to modifications of the UP to address anesthesia procedures also.

[J. Kevin Mackey, MD]

If a Chest X-ray or CT scan is mislabeled right versus left, and there is no associated clinical sign or symptom of laterality to raise a question of labeling error, following all Joint Commission Universal Protocol procedures will still result in a wrong side surgery. For example, CT Brain for headache or altered mental status that reveals a subdural hematoma on the right but CT scan mislabels it as left.

How can a CT scanner error in assigning right and left to an image? The CT scanner does not know how the patient is positioned on the CT table. CT labeling requires the input of the technician to inform how the patient is positioned on the CT table, head first versus feet first and even supine versus prone or in some cases decubitus, in order for the CT scanner to correctly assign one side of the gantry as right and the other left. A wrong patient positioning entry (human error) will result in the CT scanner assigning an incorrect label of sidedness to the images.

Most physicians understand how a chest x-ray or extremity x-ray may be mislabeled for sidedness, but few realize that the same kind of error may occur with a CT scanner.

[Ajlouny]

There's been studies on how people will agree with the norm. Maybe that's where the system failed. Maybe there should be training on how to speak out when there is a variance.

[Alan S. Black, MD]

A very similar experience occurred at my previous institution. All members of the OR team including the surgeon, the anesthesiologist, the OR nurse, and surgical technologist agreed to perform a Left Inguinal Herniorrhaphy and then proceeded to do one on the Right side. This wrong site surgery was not discovered until the surgeon was dictating the operative report in the Post Anesthesia Care Unit. Interestingly, the anesthesiologist (who was the only person in the OR with the correct orientation relative to the patient) had recorded the event in 3 separate places (anesthesia record, pre-anesthesia assessment, and his billing sheet) and failed to discover that the surgery was performed on the wrong side!