Tuesday, March 24, 2015

Oops, wrong side again.

Someone once said that there are two types of surgeons, those who have operated on the wrong side, and those who will do so.  The persistence of wrong site surgeries (worldwide) is striking, especially given the existence of the so-called Universal Protocol that is supposed to eliminate them.

What to do?  Plug away.  As each case occurs, do a full analysis of what went wrong and why, and then teach all those involved in this arena in the hospital.  Engage in a just culture, understanding that if it happened to one well intentioned surgeon, it could easily happen to someone else.  Look for the underlying systemic flaws.

Here's an example of one such review, held in a hospital in the UK, held without blame and with all participating.  In my mind, it represents an excellent summary of this particular case and provided useful results for the hospital and its staff.

After Action Review
Never Event Wrong side surgery 

What was expected :

Patient was admitted for Right sided percutaneous intervention. Patient expected to come in, have the correct procedure by doctor A under sedation and go home the same day. 

What actually happened:

Doctor A at the team huddle in the morning felt that his list might overrun due to a complex case on the list. He asked doctor B in the next theatre who had a light list if he could help by doing a case or two. Doctor B agreed.

Patient came from ward to Doctor B’s list for the procedure to be undertaken by another practitioner on behalf of Doctor B. Patient was consented in the anaesthetic room by the other practitioner.

Side of procedure not marked by consenting practioner.

Patient went into theatre and placed prone on table and sedation commenced. WHO Time-out took place after sedation commenced. Surgical site marking tick box in the Sign In ticked as done.

The Practitioner then proceeded to invasively treat the wrong side percutaneously.

No one in the team noticed error.

Patient returned to the ward only to notice that plaster over injection site was on the wrong side. Flagged it up with the Nurse who informed the treating team. Team came to ward and after checking agreed there had been a mistake. Patient returned to theatre to have the correct site treated by Doctor A under LA. Patient informed under duty of candour of mistake. 

Why the difference:

1.Unexpected patient on the list operated on by a different team.

2.Operation site not marked.

3.The Team felt that better concentration by all during Time-out might have helped. They feel that it is often the case that not everyone actually pauses and pay attention completely during time-out. Anesthetist was concentrating on the patient’s airway as sedation has already started.

4.The Surgical Site tick box on the Sign In was ticked as done even though this was not the case because ‘Doctor B never marks operation side’. Staff assumed that it was therefore all right to do so. The Practitioner who did the procedure marks all his patients except those that he does for Doctor B in order to avoid any ‘unnecessary remarks’. 

What lessons can be  learned

1.      All patients having interventional procedures to a bilaterally symmetrical organ or part of the body should be marked at the time of consent with a marking pen that will not wash off with alcohol based skin preparation.

2.      If the patient is not marked the procedure should not be undertaken until such a time as the person who consented the patient marks the appropriate side. All or any member of the team should feel empowered to ‘call this out’. Bilateral procedure sites should have a mark on each side.

3.      If the patient is not marked it should not be documented that this has been done in the WHO Sign in and staff should feel empowered to decline to start the procedure.

4.      Sedation should not be started until Time-Out is completed to allow the whole team to pause and concentrate.

5.      During Time Out all activity should stop to allow complete focus of the whole team on the checklist prior to commencement of the operation.

6 comments:

Norma Sandrock said...

From Facebook:

In other words, do what you're supposed to do and don't "check the box" if you didn't.

In the US we do the Time Out immediately before incision, making sure the correct side is prepped and the mark is visible in the field. If they do this "before sedation is begun" that allows an opportunity for a mistake, especially if the patient is going to be turned prone.

nonlocal MD said...

Well wait a minute; what about "Dr. B never marks his patients"? If it's policy to mark the patients (and this is clearly supported by science which it is), then how does he get to do things his own way? It is precisely this trait of surgeons that leads to non standard work and, mistakes.

i find it amazing the practitioner marks all his patients except those of Dr. B!! What if he is sick one day and his substitute can't remember which doctor doesn't like his patients marked? It goes on and on.

Anthony Harvey said...

Yes we see marks on a patient, consent forms written with Left/Right but never do we see a diagram of the human torso to mark with a red X before the patient has signed it.
I have a torso printed on a small sticky label ready for when I need an operation which will be stuck on my consent form before I sign it.
Why?
Because when the WHO Patient safety check is completed in the operating theatre I know this consent form will be read by all theatre staff before my operation start.

Mark Graban said...

As this shows, there's "doing the timeout" (going through the motions) and there's REALLY "doing the timeout"(being fully present).

As much as we don't want to blame... and blame can be counterproductive, it bothers me that the "unsafe behavior" (Dr. B "never" marking sites) was allowed to go on so long.

That's an intentional choice, as opposed to something that just happens that's unexpected.

What leaders knew that Dr. B never marked sites? They are just as culpable as Dr. B here.

In the "Just Culture" algorithms, we'd ask if Dr. B's act was intentional, if it was driven by the system, and if Dr. B should have known something bad would happen.

The problem is that they can get away with NOT marking the site (with no ill effects or harm) far too often... except for that one time.

The time to blame and punish Dr. B isn't AFTER that wrong site surgery. There was a system that was complicit in allowing him to not mark the site. If it were me, I'd lean toward punishing Dr. B (for the bad practice, not the bad outcome) and also punish any leaders who had looked the other way.

"No blame" can't mean "nobody is ever held accountable for their choices." A surgeon has far more choice in a system like this than, say, a nurse would.

Paul Levy said...

Well said!

Stacey Gordon said...

I marked my own body parts ahead of time. I didn't trust staff to mark them. I also wrote the words NO Stick/NO BP In large letters on the arm that had had axillary node dissection in prior surgeries. Often forgotten.