Scenario
Note: This happened to the Chair of the Patient Safety Subcommittee, and therefore this write-up will be in the first person.

The patient is a 21 year old boy who is quite well known to me, the surgeon. I was present at his baptism, my wife is the patient’s godmother, and his grandmother is my secretary. He sustained a midshaft fifth metacarpal fracture with a 45 degrees apex dorsal angulation. I met him in my office. His grandmother, my secretary, filled out the intake forms since the patient had injured his dominant hand: healthy, no medications, no allergies, never had surgery before, the entire ROS was negative. My secretary sat in on the exam, where I reviewed the chart with him: healthy, no medications, no allergies, never had surgery before, the entire ROS was negative. The hand exam showed mild tenting of the skin, and it correlated well with the X-ray: short transverse fracture, midshaft and 45 degrees angulated, apex dorsal. It would be easily reducible closed and I recommended a closed reduction. He declined and asked for an ORIF, due to his concern about his ability to play guitar. We discussed the pros and cons of the two options, he decided he still wanted an ORIF. I filled out the surgery scheduling form, “healthy, no medications, no allergies,” and handed it to my secretary. She was able to arrange the case for the next day, and his internist cleared him. I read the internist’s impression: “Cleared for surgery.”

I met the patient in the pre-anesthesia suite, the entire family, including grandparents (as noted above, the grandmother is my secretary) was present. I greeted them. I examined the hand: he had marked the site properly, I marked the site with my initials. I check my Pre-op Checklist: everything was in order, and I was about to leave to check the instruments, when for some reason I can’t recall, I casually asked, “Can you wear cheap silver-colored jewelry?” He replied, “Yes, I can wear cheap silver jewelry.” And then, as I turned away, he said, “But nothing containing nickel. I have an allergy to nickel, it gives me a rash.” My secretary piped up, “Yes, I thought you knew that.” My secretary was the one who filled out the intake form saying “no allergies,” she was present when I reviewed the chart with the patient and he denied that he had any allergies, and she was the one who scheduled the surgery, knowing that I was going to implant a metal plate, and yet she still did not think to mention the nickel allergy. Interestingly, the patient’s pre-op history and physical by his internist clearly stated that he had a nickel allergy, so he had told the internist about it on the day prior to surgery. I knew he was young and healthy (plays football), so I only read the internist’s impression: “Cleared for surgery.”

Analysis
It is important to recognize that even the best-intentioned patient and/or support team may inadvertently give you incorrect information. Even a trained and experienced medical paraprofessional such as my secretary can inadvertently give you the incorrect information. They simply do not understand all the implications of the question. In this case, the patient, my secretary, the hospital chart, and the hospital ID band all stated that he had “no allergies,” yet he and my secretary (who had filled out the intake form as “no allergies”) clearly knew he had an allergy to nickel. I was amazed and asked the patient why he did not tell me. “Doc, I thought you were asking about medications and food, I didn’t think you meant jewelry.” I asked my secretary: “I thought you knew.” To them it was obvious, to me it was not. The clear lesson: my question was not phrased in a way that it was going to reliably give me the information I wanted, or thought I was getting.

This should not be thought of as something so rare that it is unlikely to ever happen again, a “one-off” situation that is interesting but so rare that we can ignore it. While rare, it happens. In the context of “Black Box Thinking,” the book about how the aviation industry learns from its errors and the medical industry does not, this case has the potential to be a learning experience for all hand surgeons. We need to think of it as a sentinel event for each of us. Despite its rarity in any one of our practices, when considering the experience of the entire hand society, it very likely to happen in the near future. Two hand surgeons on the Committee since this Scenario was written have contacted me to relate their experience with a nickel allergy that was missed. Why do our intake forms still say “Allergy to medicine,” years after so many patients who have a nickel allergy, have had stainless implants? It is because we have not learned the lesson from prior events. If we want to know if they have an allergy to nickel, we probably need to ask the right question.

A second error I committed was not reading the entire internist’s report. It takes a lot of time, but the internist likely does not know what part of his report is relevant or not. I doubt he knows that many of our implants are stainless steel, and that stainless has nickel. I need to read the entire report, to be sure that the internist has not discovered something that I need to know, but did not get from the patient or my exam.

Root Cause Analysis

1. Systems Error

Just asking about “allergies” is not likely to reveal a nickel allergy, as in this case. Patients will likely interpret this question as a question about an allergy to medications, which is in fact the meaning in most physicians’ offices. Patients also are likely to be rushed when they are filling out the forms. Checking the “no” box is an easy way to get through the forms. The real information that a hand surgeon needs is likely not to be recorded.

2. Error in Communication

I was wrong in not reading the internist’s entire report. While I might hope that they would call me if they had a concern about any aspects of the patient’s preparedness for surgery, I cannot expect the internist to understand that stainless steel implants contain nickel, and that a nickel allergy is an important finding. I have spoken with other surgeons, who suggested that they always read the entire H&P, since it is their expectation that patients will give you an incorrect medical history. Remember, the reason for the Review of Systems is that patients forget to mention medical problems. This is not an uncommon scenario: “No medical problems, Doc!” “What about your heart?” “Oh, the MI was years ago, Doc, those stents and the blood thinners are great. I don’t have any medical problems anymore.”

Suggestions

1. All surgeons who implant metal plates should look at their intake forms and consider specific questions about nickel. All surgeons should consider specific questions about latex. The intake form needs to not only ask about “allergies,” but should specifically ask, “Do you have an allergy to nickel? What is the reaction? Do you get some skin irritation from wearing cheap, silver-colored jewelry?” In a similar light, the allergy section should also ask, “Are you allergic to latex? What is the reaction?” Simply put, we need to ask the question that is going to give us the information we seek.
2. All surgeons need to read the entire H&P. It is an error to think that the internist will bring to our attention all matters of importance.

Reference
Black Box Thinking: Why Most People Never Learn From Their Mistakes – But Some Do
By Matthew Syed. Find it on Amazon. Likely to be the best $8.21 that you ever spent.