Tuesday, November 26, 2013

Despite checklists, wrong-site surgery still occurs. Why?

Not long ago, two California hospitals were cited by the state for wrong site surgery.

At one hospital, a skin incision was made in the right groin of a patient who was to have had a left orchiectomy. Fortunately the error was discovered, and the skin was closed. The correct testicle was removed. To his credit, the surgeon told the patient and his wife what happened immediately after the operation.

An investigation found that the patient's groin had not been marked. The time out did not prevent the error because the OR team did not verify the operative site as the protocol mandates. In other words, they had gone through the motions.

The hospital was fined $75,000.

The other California case did not turn out as well. Instead of removing a cancerous left kidney, surgeons did a right nephrectomy. The error was not discovered until the pathology report was reviewed. A number of assumptions and misunderstandings contributed to this error for which the hospital was fined $100,000.

Both hospitals made the usual system and protocol corrections that are precipitated by any state investigation. But these were human errors and will likely happen again. The existing policies were adequate. They simply were not followed.

Another case that occurred in July is from Florida. A surgeon performed a vascular procedure on the wrong leg. Apparently, a nurse anesthetist noticed the error during the case and spoke up, but the surgeon didn't stop. He finished the wrong leg and then did the correct leg too.

When the patient awoke, the surgeon asked her to sign a consent form for the wrong leg and told her that she had needed that surgery anyway.

The hospital failed to report the error for two weeks.

In the Orlando Sentinel article, a hospital spokesman said, "We have policies in place, and training in place, but the system broke down because of the human element." I think he was admitting that the incorrect procedure was the result of a human error, but I'm not sure.

A state inspection found many issues, and the hospital has been threatened with termination of its Medicare and Medicaid provider agreement.

It appears that operating room checklists, for all their promise, are not working out as well as they should.

Two recent papers looking at three distinct hospital settings, have found that checklist use and completeness are less than ideal.

At Scott and White Memorial Hospital in Texas, researchers found that OR checklists were used 94% of the time, but 54% contained inaccurate data and 15% were not fully completed. Compliance with the "time out" portion of the checklist was found in 77.8% of cases.

The paper appeared on line in the Journal of the American College of Surgeons.

In a Medscape report on the study, the senior author was interviewed and said that some of the hospital's surgeons did not "buy in" to the concept. 

Dr. Atul Gawande, commenting on the paper, wondered if scrubbing 94% of the time would be acceptable and speculated that using the checklist was not the norm in that institution. Gawande also suggested that one-on-one contact with every surgeon might be the way to improve checklist use.

A paper from the UK published in BMJ Open looked at OR checklists in two hospitals in the UK and one in sub-Saharan Africa. Staff from all three were interviewed extensively.

The authors found that the rate of checklist use was better in the UK hospitals than the one in Africa, but like the Texas study, checklists were not used 100% of the time. Accuracy was also inconsistent. Completeness was noted to be variable especially in Africa, and there were many lapses in performance of checklist components. 

An OR nurse in the African hospital said, "Even though training on the checklist was given for surgeons, they don’t use it, they don’t believe in this bit of paper, because mostly they said, ‘we don’t mistake the identity of the patient, it doesn’t happen that we get the wrong patient.'"

An anesthetist in the UK said, "We’re trying to prevent what are usually rare errors, rare mistakes, you know, the majority of the things on that checklist are done most of the time without the checklist, but every now and then [...] you forget to check if you’re operating on the right leg and not the left leg, and that’s rare, but on very rare occasions it then leads to a disaster."

What have we learned here?

We have a long way to go until the checklist becomes a real factor in preventing errors. 

We all agree that this sort of mistake should never occur. Until surgeons accept this and lead the way, harm will come to patients.

Or, maybe we need a checklist to ensure that checklists are being used.


Anonymous said...

Strangely, and tragically, only weeks after the near-miss (ochiectomy) in the first hospital you mentioned, they *did* do a wrong-side nephrectomy! Apparently there had been some confusion during the initial (pre-hospital) work-up, though the site had been defined by the time of the operation. In the OR, the surgeon forgot his computer logon and decided to go ahead without looking at the CT scans.


Skeptical Scalpel said...

Anon, thanks for the update. It's hard to believe that could have happened in the same hospital and so close in time to the first case.

Anonymous said...

We have had serious problems with wrong side surgery at my hospital too (Canada). This was while the checklist was "enforced". I find that most people ignore the checklist as it is being done. Just like you say — going through the motions. If people are not engaged, bad things can happen.

Anonymous said...

You are absolutely correct in that surgeons have to buy into it. Many do not, and that goes for the rest of the OR crew as well. Some of them are doing other things, and I bet others are just mentally blanking at the rote recitations, similar to frequent fliers listening to the mandatory safety instructions.

One big defect is that the surgeons, and to lesser extent anesthesiologists, can bypass checklist items with little consequence unless stuff hits the fan. Of course, the rare but disastrous events are exactly what checklists are designed to prevent. In most places, no one is going to stop a surgeon from cutting if he wants to go ahead without relevant Xrays.

For example, the 2 wrong nephrecromy doctors mentioned on this thread still have their licenses and their OR privileges, though they clearly violated hospital policies. Wrong patient and wrong-site surgeries should be zero-tolerance and result in automatic license probation and loss of independent operating privileges for a few years.

Henna said...

Anon 3's comment interests me the most, that for surgeons there is "little consequence unless stuff hits the fan." As a nurse, I think that is the vital point. Protection of her/his license is near the top of a nurse's thoughts. You probably know this, Skep, from your wife. I do not see doctors worrying about their licenses in the same way. I can guarantee that if a nurse's actions resulted in a near miss, she would have a reprimand placed on her license and would probably be fired. The reprimand alone is enough to make it very unlikely that she would ever work again.
If you want an interesting conversation, ask a good nurse how she protects her license and why that is paramount to her.
A student nurse that I knew drew up the wrong dose of insulin. She did not notice the error, but her instructor did. (The dose never got near the patient.) Her instructor corrected her and sent her home from clinicals for the day. Then the instructor reported the near miss to the nursing school administration, who suspended her for the rest of the term, thus requiring her to repeat all her classes for that semester. Some people thought this was drastic considering that the student was only a student, but I think it speaks volumes about how seriously nurses take a near miss. (This happened just a few years ago; it's not a story from the dear old days.) Doctors close ranks. Nurses throw each other under the bus.
I apologize for the she-ism, but the vast majority of nurses continue to be female....
I like Dr Gawande's comment on whether scrubbing 94% of the time would be acceptable.

Anonymous said...


I would hope that the great majority of physicians and nurses have the well-being of their patients at the top of their list, and not worries about licensure.

I don't agree that every (or most) nursing error gets to the disciplinary stage, and he/she loses the job. I have seen plenty of counter-examples.

Do hospitals treat doctors and nurses' malfeasances differently? Yes. They depend on doctors to bring in patients and will give them a lot more leeway. That isn't going to chang in the forseeable future.

Henna said...

Anon 4,
Most nurses, like dcotors, have their patients' well-being at the top of their lists. But I still believe that nurses, far more than doctors, think about how to protect their licenses. Talk to nurses about that and I think you will be surprised. Talk to an experienced med-surg nurse, talk to nurse managers, talk to nursing professors. In my senior preceptorship, I was told by the unit manager, "Chart like your license depends on it, because your license depends on it." I think that most nurses receive that message early in their careers, and it permeates more than just charting.
As a nurse, if I made an error in the OR that resulted in harm or a scary near miss that was known to the entire team and to the hospital admin, I'd be out of a job first and questions would be asked later. Yes, I would be worrying about whether I'd be hauled up before the state board of nursing.
I didn't say that most nursing errors get to the disciplinary stage. (I think that most nursing errors are covered up by their perpetrators, or if done unwittingly, often aren't identified until a situation is reviewed.) My point is that nurses ARE reprimanded, to the stage of revocation of licensure, more often than doctors. It's not only a matter of the hospitals' attitudes. The propensity for action of the state regulatory boards and the culture of the professional bodies are simply different.

Anonymous said...


You are just wrong.

Most nurses don't go around worrying about their licenses. Yes, if you make an egregious error you will be disciplined, but you are not going to lose license or job for it. Repeated offenses: yes. If you repeatedly screw up - in any field- should you not lose your job?

Look, I am a doc and I have on many occasions took responsibility for what is obviously nursing errors. I am in charge and I don't blame my subordinates.

It is sad that a nurse thinks that his/her primary duty is to chart to cover actions. Your - and my - responsibility is to take care of the patient.

Anonymous said...

my problem with this is form over function. in my hospital i as i have for 30 years insist that the ct is in the room for that patient. i put it on the viewer and the team idetifies the pathology. i do this in lue of marking. i am told this in violation of joint comission standards. really? really?

Libby said...

I'm just glad that when I've gone into the OR I'm still mostly awake (I won't be taking pre-meds anymore, anaesthetics & my body don't mix very well) and remind them what they're suppose to be doing while I'm in la-la land.
Back in '85 we were told to chart as though you were in court. I was also disciplined due to a drug issue. I didn't give Demerol to a post-op patient because after we talked about it, she decided she didn't want it. My clinical instructor called me at home and took a strip off of me for not taking advantage of giving a injection. Gosh, silly me, thinking that the patient could think for herself instead of giving a shot because I needed to give one. The instructor said SHE gave the injection. I wan't suspended or anything, not that she'd have a leg to stand on because I did exactly what we were told we should do in pain management. (I had to chase that post-op patient down the hallway the day after her hernia surgery-she was a Jazzercise instructor & in amazing shape. And alert. Unlike my instructor who I would report if I ever had one like that again. She did so many things that were horrid to patients it blew me away).
Being human gets in the way of perfection. Or just being wise. I would think that doing the right thing in the right place would be in the top 2 things a surgical team would REALLY want to do. Isn't that what Sharpies are for? "Cut here X"

Anonymous said...

I am an aging scrub nurse. In the old days of hospital diploma schools, the mentality was one screw up and you are gone. It did not really mater if the outcome of your error was benign. Henna is correct it was pounded into your brain that your license was at stake all the time. I think people are more enlightened today.

Skeptical Scalpel said...

Thanks for all the comments. I would point out that the Joint Commission does not like the use of a "X" to mark the incision site. An X can be interpreted as "No." They prefer the use of the surgeon's initials as long as his name is not "Nathan O'Brian." (NO)

Libby said...

How about "cut on dotted line"? :o)

Skeptical Scalpel said...

I think that's OK.

Anonymous said...

I think it is clear that no amount of policy can substitute for actually conscientiously doing what the policy says. And enough of it doesn't apply to me because I am too cool for such trivialities.

Skeptical Scalpel said...

Anon, aren't we all?

Lizzie RN said...

I am a BSN RN, working as an OR circulator here in NY. I finished nursing school two years ago. I am appalled to read the response of the anonymous doc to Henna, above. She is right on the money. Despite the hopes of the anonymous scrub nurse, things are not significantly more enlightened. I was told over and over in nursing school to chart like my license depended on it. When nurses are forced to work under unsafe circumstances (to us, this usually means understaffing) they talk about their licenses being at risk. If you walk in the break room, if a nurse finishes up a bad story she will often say, "I told (fill in the blank), 'not under MY license!'"
I don't think that anonymous doc reads very carefully. Henna did not say that she thought a nurse's primary responsiblity was to chart to cover actions.
I believe we do put the patient first. I don't know of any nurse who loves/lives to chart. But as a nurse myself I would say that we see our documentation of direct care as part of the total picture of caring for the patient.
I've shown this post to most of the RN staff on my pod team. All of us agree that whether we went to school forty years ago or graduated last year, protecting our license is high on our list. We also think that anonymous doc is a jerk and we suspect him/her, or a clone, to be on our staff!

Skeptical Scalpel said...

This all goes back to the culture of blame that exists in nearly all hospitals. I think it's really sad that people feel they have to worry about their licenses all the time. And the patient safety movement wonders why things get covered up.

Unknown said...

Time out is based on " read and do " which does not work.
A good checklist must has only " killer items "( that means if you miss -->you die) to prevent long checklist syndrome. Done and check concept of checklist in aviation takes only 5 second to complete the checklist instead of 3-4mins compare to surgical timeout.

Skeptical Scalpel said...

I agree that checklists can be too long and full of trivial items. But I think the aviation checklist takes a lot longer than 5 seconds to complete. Here is a typical example of a pilot's checklist http://flighttraining.aopa.org/students/presolo/skills/checklist.html. It has about 27 items on it.

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