Wednesday, November 28, 2007

Wrong Side Surgery

There is another incident of wrong side surgery in the news. I find it as difficult to fathom as I do leaving a baby in a hot car, but we know that happens to0 often (once is too often for either).

"The Rhode Island Department of Health reprimanded Rhode Island Hospital today, and fined it $50,000, for its third wrong-site surgery this year, the most recent involving an 82-year-old patient in the neurosurgical intensive care unit.

The incident at the Providence hospital occurred Friday, when a resident, a doctor in training, began drilling into the right side of the patient's head during a bedside procedure. A CT scan had shown bleeding on the left side of the patient's brain. The resident realized the mistake, stitched closed the initial incision and performed the procedure on the left side." --White Coat Notes

Wrong-site surgery is a medical error that should never happen. It is not a medical risk that the patient must accept. Legally, it qualifies under the principle of res ipsa loquitur. The National Quality Forum (NQF) includes wrong-site surgery events on its list of Serious Reportable Events (commonly referred to as never events).

Wrong-site surgery is surgery that is:

  • done on the wrong patient--8%
  • the wrong procedure--9%
  • the wrong side of the body (ie, as above, or left knee rather than right knee)--70%
  • or the wrong part of an anatomic structure (ie wrong spinal level in back surgery, wrong finger in the correct hand) --14%

Above percentages taken from the MedScape article listed below.

Wrong-site surgery is a core patient safety problem. It is the responsibility of everyone who is part of the patient's care. "The actions of surgeons in verifying the reconciliation process in the preoperative area were found to have the greatest net positive contribution (+42), followed by the patient or family (+38) and then verification against the surgeon's office records (+29). Nurses in the preoperative area and those circulating in the operating room were equally effective at identifying errors (+17)." Suggestions for preventing the occurrence of wrong-site surgery:

  • The surgeon should be fully engaged in the formal time-out. He/she should consider a full preoperative briefing.
  • The surgeon should be explicit about the procedure and its indication(s), including the side or site as appropriate. This should be included in the patient's records (ie H&P).
  • The consent should be obtained from the patient by the surgeon, explicitly stating the procedure including the side or site as appropriate.
  • There should be a reliable system for accurately transmitting information from the surgeon's office to the OR nurse.
  • Have an initial-time out in the OR before caring for a patient undergoing elective surgery.
  • The marking of the operative site should be reconciled by the surgeon and patient together.
  • The surgeon should discuss new findings and changes in plans with other members of the operating team.
  • Labeling the specimen--reconciliation should include the surgeon, the operating technician, and the circulating nurse. There should be a chain of custody for irreplaceable specimens.
  • Multiple and ancillary procedures should be included in the formal timeout.
  • Repeat formal time-out processes for independent procedures.

Most important is for everyone involved to be engaged in the process. Remember why we are in the operating room. It is to take care of the patient--someone's mother or father or brother or sister or daughter or son. Tomorrow it may be one of us. Take care.

Reference

Getting Surgery Right, Preventing Wrong-site Site Surgery--MedScape Article

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery ™ -- the Joint Commission

Wrong-site Surgery-- Agency for Healthcare Research and Quality

1 comment:

Dr. Smak said...

Our surgeon wrote his initials on the back of Henry's head the day before the surgery. I thought it was a smart idea.