Friday, November 23, 2012

How to operate on the wrong site

Here’s a story that illustrates how to operate on the wrong site. 

In a news article about some sanctions that the State of California imposed on certain hospitals for misdeeds, the following summary of one incident appeared. I have added some emphasis in bold.

A six-year-old boy had to undergo a second surgery to remove a growth after a surgeon performed the wrong surgery on his tongue.

"This failure resulted in [the patient] being exposed to the risks of bleeding and infection, and unnecessary exposure to the risks associated with anesthesia that was needed to perform the right procedure," state documents say.

The surgeon told investigators that he couldn't be sure whether a time-out [explanation: a pause in the preoperative routine to ask all members of the OR team if they all agree on who the patient is and what the operation will be], which was said to have transpired according to the hospital's policies, was ever done.

"Either time-out was not done or it was done, but I could not recall what procedure was said," the surgeon told state investigators. The surgeon then said that team members, who should have known the correct procedure, should have asked why there was no specimen of tissue from the removed growth.

Asked whether he examined the patient prior to the surgery, the surgeon replied, "Usually, I don't examine anybody. In this case, there was no time to do pre-operative visit. From now on, I need to see the patient prior to surgery."

The hospital was fined $50,000.

I can’t blame anyone who read that story for wondering just what the hell we are all doing in hospitals today. 

The wrong operation, a tongue-tie release, was performed. The surgeon couldn’t recall if a time-out was done. He blamed the staff for not mentioning that no specimen was obtained. He apparently had seen the patient in his office but did not re-examine him on the day of surgery and did not usually do so. It’s not all bad though. “From now on,” he will start seeing the patients before he operates. 

The official report cites the hospital for failing to follow its own procedures regarding verification of the type of operation to be performed. 

It is basic good practice and common sense to examine every patient again on the day of surgery and reconfirm the nature of the procedure, the correct side and answer any questions the patient or family might have. For example, I have seen lymph nodes that I was asked to biopsy shrink dramatically in the 10-14 days between my office examination and the planned surgery day.

Who obtained consent from the child’s mother? What did the consent form say? Didn’t the circulating nurse or anyone else look at the form to verify what operation was to be done? Don’t the nurses enforce the time out rule? What was the anesthesiologist doing?

Maybe the fine and the hospital’s “system error” type plan of correction, which entails monitoring 30 time outs per month for an unspecified period of time, will prevent this from happening again.

I doubt it. 

See how easy it is to operate on the wrong site? That’s why people can defeat any system correction plan.


RobertL39 said...

The "Medicine as Swiss Cheese" metaphor applies here. You are correct; NO piece of swiss cheese is thick enough to stop every error. Obviously, as it appears that virtually nobody did their job (jobs which are there to make sure the cheese is mostly cheese and not air), the piece of cheese in this institution was ridiculously thin.
Additionally, your end comment is, I think, misdirected. People usually CAN defeat any 'system correction plan'. But the implication is that they have to WANT to. Surely that's not the case here. 'System correction plans' are there to be sure the cheese is substantial, both in texture and thickness, so that inadvertent error (falling through holes all the way through the cheese) is rare.
See the recent Medscape on reduction in surgical mortality and morbidity from the institution of peri-operative checklists.

Skeptical Scalpel said...

Robert, thank you for commenting. People don't necessarily *want* to defeat plans of correction. I think it is more likely indifference and/or laziness. I am sure that hospital had a time out process in effect. It's a Joint Commission requirement.

I had seen that German checklist paper. It really isn't the WHO checklist, but rather it's a modified version. Like many checklists, it has too many items on it.

Also, the paper is a "before and after" study which can easily be confounded by the Hawthorne effect.

It would be interesting to see how compliance with each item on that checklist is after a year or two.

Viscot said...

Fantastic article.
And in regards to the comment above, I think indifference is often the issue. Sometimes these time out procedures become so mundane and monotonous that the staff just go through the motions without actually checking.

Skeptical Scalpel said...

Thanks for the comments. It may be similar to "alarm fatigue." When you hear hundreds of false alarms, the one that's real is easily overlooked.

Anonymous said...

I worked at several hospital through out my career i feel that hospitals all do not provide for there patients 100% all all the time. This a true statement and most circulators and scrub would agree..

Kathy, London,England said...

The surgeons always blames the nurses!However as a theatre team,we are all equally responsible for the patient.The team leader in the theatre should take the lead in the anaesthetic pause and with the use of the WHO checklist, ensure that the checks are correctly performed and the team aware of the correct procedure.Yes,it may be mundane,but we are only there for the safety of the patient and the more checks we do,the less chance of wrong site surgery.

Skeptical Scalpel said...

Those darn nurses! I found the surgeon's excuse "that team members, who should have known the correct procedure, should have asked why there was no specimen of tissue from the removed growth" laugh out loud funny. It is what stimulated me to write the blog.

Anonymous said...

Lack of engagement as a "team" in the OR. Surgeons who are allowed to not follow policy and procedure and OR nurses tired of being ignored by surgeons when they call them out of it. Weak leadership, MD driven hospitals.......all add up to errors.

Rachel J. Kwon said...

Great post and insightful comments. I respectfully disagree with Kathy in London that 'the more checks we do, the less chance of wrong site surgery' -- I would argue that more checks lead to complacency and potentially an INCREASED number of errors. If you are the last person to check something (i.e., planned surgical site) and you know that 20 people have checked it before you, are you more likely or less likely to check it as carefully as if you were the only person to check? The concept is similar to your analogy of 'alarm fatigue', Dr Scalpel (if I may call you that).

Regardless, I think it's too simple to trace error to one factor, e.g. surgeon arrogance, poor teamwork among theatre staff, inadequate checks, etc. In reality all of these contribute to lack of an overall safety culture and that is likely why it is so difficult and maybe impossible to completely eliminate error in surgery.

To counteract my defeatist ramblings: there is a growing body of promising literature on systems and human factors methods for improving safety in surgery. See (by Charles Vincent and colleagues in Annals of Surgery, 2004), and (by our group in Oxford in BMJ Quality and Safety in 2009).

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