On June 10, 2013 a 32-year-old "heavily" pregnant woman was reported to have died after having an ovary removed instead of her inflamed appendix. As the infected appendix festered, she became septic and succumbed to multiple organ failure. This tragedy occurred in the UK in late 2011, but has just come to light.
How could this have happened?
Let me count the ways.
The surgery was performed by two trainee surgeons. Their level of experience was not stated.
The senior staff, called consultants in the UK, had gone home for the day.
The operation to remove the appendix was apparently done as an open procedure, not laparoscopic, which is acceptable if done correctly. The articles say that the surgeons had to take out the organ by feel and not under direct vision, which is not proper.
Although an ovary can be enlarged during pregnancy, under no circumstances does an ovary look or feel like an appendix. As in another case described below, inflammation can cause confusion at times, but not to this degree.
The woman was discharged a week after the initial surgery but returned with pain some 10 days after the removal of the wrong organ. During that time period, no one had checked the pathology report. The mistake was discovered by a doctor reviewing the patient's records during the readmission.
An abscess was drained but the she died on the operating table during a futile attempt to at last remove the appendix.
Last week, the CEO of the hospital sent a written apology to the family promising to correct the dreaded "system errors." Too little, too late.
Yes, there were system errors.
But what about human errors?
Trainees were allowed to undertake a supposedly routine operation without supervision. However, as this case shows, an appendectomy during pregnancy can be very difficult. The uterus is in the way, and its increasing size may displace the appendix from its normal position. This type of surgery cannot be done by "feel" alone.
Commentary from UK physicians on Twitter suggests that all the facts of the case, such as what communications took place between the trainees and their supervisor, have not been made public. They also point out that it is not mandatory for a consultant to be present in the operating room for every case as is true of the resident-attending surgeon relationship in the US.
But I doubt that many US surgeons would allow residents to operate independently on a pregnant patient with appendicitis. At the very least, the attending would have been in the OR, if not scrubbed.
Did the trainees ask the consultant for help when they found themselves doing an appendectomy by feel?
The surgeons did not look at the pathology report, a major omission. But what about the pathologist? If a pathologist receives a specimen labeled "appendix," and he finds only an ovary, wouldn't the prudent pathologist pick up the phone and call the surgeon?
There is also "failure to rescue." When the patient was readmitted, earlier recognition of sepsis and more timely intervention might have saved her life.
I am aware of a similar case in which an inflamed piece of fat was removed by two unsupervised trainees who mistook it for the inflamed appendix. On the following day, the pathologist called the attending surgeon to tell her that the appendix was not present in the specimen. The patient was promptly taken back to surgery. He wasn't too happy, but he was alive.
The hospital's investigation of this case should have taken a few days at most. If the media reports are true, disciplinary measures and remediation should have been promptly instituted. An apology should have been offered far sooner than it was.
“An extensive trust-wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again" and "… to improve systems and patient safety," said the hospital's CEO.
As I have blogged before, system changes can be instituted, but can be defeated easily by carelessness, inattention and lapses of common sense by one or more individuals.
Stories about this from the UK media here
and here.
Search this blog for "system error" to view other posts on system
errors.
ADDENDUM April 15, 2014
For some follow-up on this sad story, click here.
ADDENDUM April 15, 2014
For some follow-up on this sad story, click here.
11 comments:
A colleague of mine sent a "hernia sac" as specimen. The pathologist called the next day to say that the sac contained bladder. He said he even read the operative note to make sure that it wasn't part of the case. I was impressed and am forever more appreciative of all specialties. We can't do it alone.
That being said...no attending I know, myself included, would leave any trainee alone to operate on a pregnant woman. We'd even have OB there to monitor the fetus.
Thanks for commenting. We see pathologists and radiologists calling us all the time with questions. It's a good trend.
Just what is "heavily" pregnant? I did an open appendectomy on a lady who was about 6 months pregnant just this past weekend. She weighed about 370...is that "heavily" pregnant?
It wasn't that difficult to expose the pericecal region, perhaps the enlarge uterus pushed it toward the surface. I certainly didn't have to operate by feel. I could have done a lap, but my op time was only 39 minutes. I dare say I could have handled it without too much problem when I was a mid level resident, but there is no way I would let trainees operate on a pregnant patient without supervision.
No excuse imaginable for not following up on a path report. Do they order labs and x rays and ignore them as well?
I agree heavily pregnant is a bit vague. There is a photo of the poor woman and she looks pretty far along to me.
Good question as to what else they might ignore.
I believe as an industry we have gotten to used to chalking things up to "systems failure" that we too often fail to hold individuals accountable for their actions and decisions.
I agree. Sometimes it really is someone's fault.
Bottom line: systems and protocols don't operate (although now that robots do, who knows?) I'm becoming a dinosaur, but I believe that clinical judgment is being suspended by "protocols". Hard to figure out how this situation, even as outlined, is justifiable anywhere, though
So far robots don't operate by themselves. It should really be called "robot-assisted" surgery. I'm not sure what protocol was in effect for this case.
Surgical “residency” in the UK consists of 2 years of internship (Foundation 1 and 2), three years of core surgical training, two to three years of specialty surgical training, and then a year or two as a Surgical Registrar. Each step is competitive. A Registrar is commonly a PGY-8 or 9 grade. One does not get to be a “consultant” (attending) until a post opens up, one can stay a Registrar or staff grade forever until this happens. It even takes five post grad years in the UK for someone to be a GP. Trainee does not mean the same there as here in the US.
Anon, thanks for the explanation.
As I said in the post, the level of training of the two surgeon trainees was not stated. The story implied that supervision was in order for them but not provided. If the details are true, they could have used some help, regardless of their level of experience.
I review all of my pathology reports and most of the pathology slides of all tissues removed from my patients. Besides having a great relationship with every pathologist at my hospital, reviewing reports and tissues is a good learning tool for me.
Under no circumstances was I, as a resident, allowed to operate without an attending physician in the OR. He/She might have been reading a journal or watching what I was doing over my shoulder but he/she was there. I never allow any trainee to do anything except close skin without my presence in the OR.
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