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Patient Safety Scenario #4: Wrong Side, Wrong Site, Wrong Patient: You Can’t Depend on the Patient

This essay is the fourth installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s “Black Box Thinking” in order to inform and improve our medical safety record. To read earlier essays and learn how to contribute, please click here.

 

Introduction

Many surgeons have the impression that patient safety is limited to the correct side, site, and patient. This series on patient safety has intentionally started with scenarios which highlighted other important issues in patient safety in the operating room. This installment will review five different instances where mistakes were made with respect to side, site, or patient, and the system failed because the staff and surgeon depended in part on the patient to catch the error. The system of checks has to be so tight that it does not solely depend on the patient’s cooperation or knowledge of procedures. Each of these scenarios actually occurred; the names are changed for confidentiality.

First case: During an office visit, a patient complained that multiple fingers were triggering, some were more bothersome than others, and a discussion was had about the pros and cons of observation, injection, and surgery. Eventually she decided that she wanted an injection, for two fingers. The surgeon touched the ring and middle fingers, and asked if these were the two she wanted injected. She agreed. The surgeon held first the ring finger, then the middle finger, and in each case prepped the digit with alcohol, then gave the injections. He asked the patient how the injections went. The patient replied, “Why did you inject those fingers?” The surgeon was stunned: he had just asked if these were the two fingers that she wanted injected, and he had held them as he prepped and injected them. If these were not the two that she wanted injected, why did she indicate that these were the correct digits? And why did she not say something as he held them to prep and inject them? Her response was: “I didn’t understand what you said or what you were doing.”

Second case: A patient was having right shoulder surgery. The surgeon completing a prior case and to improve turnover time the anesthesia team started the block prior to the surgeon talking with or marking the patient’s arm. The anesthesia team introduced themselves to the patient, instructed him that the surgeon would be with them soon. They prepped the shoulder as the patient observed them, and administered the block. The technical details of the ultrasound machine and the correct administration of the block were their focus. The block was done safely and successfully, and a bit later the surgeon arrived and was interviewing the patient. He noticed the wrong side had been blocked. He was shocked that the patient, an engineer who he considered to be a very responsible and competent man, would passively sit there and let the anesthesia team block the wrong side, and not speak up. The engineer replied: “I knew the nerves crossed at some point, don’t they?”

Third case: Mrs. Jones was having a colonoscopy, but was very nervous about the procedure. She was so nervous, the decision was made to perform the procedure in the main OR. She was dreading the procedure and was rather keyed up, sitting there in her hospital gown, IV in her arm and waiting to hear her name called. The nurse came in somewhat of a rush, looking for her patient. “Mrs. Smith?” she called out, hopefully. The patient reflexively raised her hand, and the nurse went to the bedside and tried to calm the patient. She was wheeled into the room and they started prepping her leg. She asked, “Why are you prepping my leg? I am here for a colonoscopy!”

Fourth case: A patient had a motorcycle accident and was scheduled for an ORIF of the navicular. The informed consent form was quite clear as to the procedure: “ORIF right navicular”. The patient was from an Eastern European country and did not speak English as a native language. The surgeon, a general orthopedist, was slightly delayed and the anesthesiologist met the patient first. He read the medical history as related in the internist’s note, which said that the patient was in an accident and was having “orthopedic surgery”. The anesthesiologist verified the patient’s health history and medications, the fact that the internist had cleared the patient for surgery, and that they were fixing the right navicular. There was some confusion when the anesthesiologist was speaking with the patient about the block due to language problems, but he felt that he had adequately communicated with the patient. The anesthesiologist placed a supraclavicular block in the pre-anesthesia room. The surgeon became available soon afterward and met the patient. He wondered why the anesthesiologist had blocked the right arm. The right navicular indeed needed fixing, but the patient had a foot injury. The other navicular.

Fifth case: Mrs. Mari Rodriguez was scheduled for a hernia repair. She was sitting in the pre-anesthesia holding area, a bit bewildered by all the fuss and protocols. She did not speak much English and did not understand what all was going on. The OR board was rather crowded that day and everything was behind schedule, as usual. Dr. Handley does not like to be kept waiting, so everyone was trying to hurry. The nurse came in, looked at the name on the board, her patient was in station 3. She greeted the patient but was frustrated that the language barrier did not make things move along as quickly as she wanted. The patient was brought into the room and given an anesthetic. She was placed into the lithotomy position and prepped the way Dr. Handley preferred, and he came in the room as the drapes were being placed. The time out identifying the patient and the procedure was done. He expertly performed the hysterectomy, and as the room was being turned over it was noticed that the patient that they had operated on, Mrs. Mari Rodriguez, was there for a hernia in another room. The nurse had instead brought in Mrs. Mary Ramirez.

 

Analysis

All of the above scenarios have actually happened. Most, but not all, occurred prior to the current regimen of depending on two independent identifiers, eg, name and birthdate, but are provided to illustrate the many ways that wrong side, wrong site, and wrong patient procedures can happen, even in the office. Circumstances, patients, and OR staff are so varied that Murphy’s Law is continually being proven true: if a wrong thing possibly can happen, it will happen. The system of checks needs to be precise, comprehensive, and so accurately followed that the chaos of the OR (and Murphy’s Law) cannot defeat them.

The surgeon cannot depend on the hospital’s system or even the patient themselves to prevent wrong site, wrong patient, wrong procedures from happening: there are still too many possibilities for error, as these five scenarios demonstrate. You need to develop your own system, within the structure of the OR, that protects you and your patient from mistakes. Personally signing the site is best; if a resident or fellow is signing, they need to be familiar with the patient and the procedure and not just depending on the paperwork as transcription errors occur. Concurrent surgeries have their own increased risk for errors, and the surgeon needs to develop a foolproof system for when they are not present at the beginning of a case, which is the classic moment where an error starts. Having the patient actively involved and writing something unambiguous on the site of the incision is a powerful tool, and patient participation is required by the JCAHO Universal Protocol, if they are able to do so (https://www.jointcommission.org/assets/1/18/UP_Poster1.PDF). However, as these five scenarios demonstrate, patient participation is not foolproof.

One option is that the surgeon can easily make their own personal checklist, independent of anything that the hospital requires. The personal surgical checklist can contain only the key elements that you want to have on your list. It is preferable that this be filled out in the office by the surgeon in their own handwriting, at the time the surgeon and the patient make the decision to proceed with surgery, and the surgeon can bring this sheet into the OR for the timeout: transcription errors are effectively eliminated. The surgeon should consider being the one to run the time out, from their personal checklist, as they are the only one who knows the patient, the indications for surgery, and the precise surgery to be performed. The Checklist Manifesto is a powerful book and should be read by every surgeon.

Language difficulties have been the source of many errors, and an interpreter service should be used when there is doubt about the patient’s understanding of and comfort speaking English. Title VI of the Civil Rights Act mandates that interpreter services be provided for patients with limited English proficiency who need this service. http://www.aafp.org/afp/2014/1001/p476.html

The actual site of the incision should be the location of the surgeon’s and patient’s marks. Many wrong sites have occurred because the marks were covered by the drapes or were capable of being misinterpreted (writing “trigger finger” on the palm, for instance, does not indicate which finger or fingers are to be released).

Patients do not understand blocks, and to some of them, a left arm regional block for right foot surgery makes as much sense as an IV in the left arm for a right foot surgery. The anesthesiology team needs to communicate to the patient what they are doing. However, not all patients feel empowered to object to something a physician is doing, and presume that the doctor or nurse is right or they would not be doing it. Do not depend on patient cooperation. There must be a timeout before any part of the procedure, including the regional block by the anesthesiologist or a local block by the surgeon.

 

Root Cause Analysis:

1.  Communication Error
Communication error has been found to be the chief source of error in many studies. (Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010 Oct;145(10):978-984.; https://jamanetwork.com/journals/jamasurgery/fullarticle/406371). In each of the cases above, a critical communication error occurred. In the fourth case, the first problem is that the anesthesiologist is not used to reading the surgeon’s indications note prior to seeing the patient. He read the internist’s note, which usually has more useful medical information than the surgeon’s note regarding medical issues, but only the orthopedic surgeon knows how long the case might be, how much blood loss, any anticipated complexities, etc. The anesthesiologist presumed that the problem was a fracture of the navicular of the hand because the permit stated “ORIF right navicular”. Reading the surgeon’s indications note would have solved this problem.  The navicular of the wrist was renamed the scaphoid by the Nomina Anatomica Convention of 1956, to avoid confusion between the navicular of the wrist and the navicular of the foot. The surgeons, the radiologists, the anesthesiologists, and the hospital need to use the correct nomenclature. Using the old term “navicular” for the scaphoid is a set up for an error.

2.  Knowledge Error 
The second problem in the fourth case is that of “positive confirmation bias”, that is, the anesthesiologist probably has done more hand cases than foot cases, and so he “knows” what the navicular is, and therefore presumed it was the wrist. It did not occur to him that it could be the navicular of the foot, so he did not check. His positive confirmation bias blinded him to his ignorance.

3.  Failure of Crew Resource Management 
Another common problem is that the surgeon and the anesthesiologist were not working as a team, but as separate individuals on separate missions: one is doing surgery and the other is doing the anesthesia. This is not the best approach, as has been amply demonstrated by the Team-STEPPS program that came out of the Defense Department and the Agency for Healthcare Research and Quality (AHRQ) https://www.ahrq.gov/teamstepps/index.htm. The best approach to surgery is the team approach: everyone is concentrating on the entire mission (successful and safe surgery), not just on their part of the mission. The surgeon and the anesthesiologist should always discuss a case prior to initiating any part of the treatment.

 

Suggestions:

  1. Encourage your anesthesiologist to read your indications note. This starts you both out on the same page.
  2. Always talk to the anesthesiologist prior to beginning any part of the case. Take a team approach to the surgery, and avoid getting isolated in your silo. The anesthesiologist and surgeon should consider discussing the choice of anesthesia as an essential part of the pre-anesthesia workup. There are situations where a block might be great from the anesthesiologist’s point of view, but the surgeon may have a concern (eg, a procedure with a high risk of compartment syndrome, a very nervous patient, or a procedure that requires monitoring of motor function intra-operatively postoperatively), that falls outside of the anesthesiologist’s expectations.
  3. It has been recommended that the surgeon lead the timeout, with appropriate team participation, before beginning any part of the procedure. Insist that each member of the team actively participate. For instance, ask the RN to read the procedure, the anesthesiologist to state the allergies and any antibiotics to be given, the scrub tech to state what implants are available. Active participation will build a safer team.
  4. Create your own checklist that contains only the information you want at your fingertips. Bring it into the OR.
  5. Use the interpreter services if there is any doubt about the patient’s command of English, their understanding of what you are discussing, or their willingness to have this type of conversation in English.

 

 

 

 

Comments (3)
Monica Wood
June 15, 2018 3:55 am

These are all gut-wrenching cases. One of my habits is to stand on the side of the bed where the surgical site is when talking to the patient in pre-op and marking the site. That way I can envision myself in the OR on the same side. Once in the OR, if the set-up doesn’t fit the mental image I have prepared, it’s another way to catch an error before it’s too late.

I also took time to get to know my patients. It meant seeing fewer, but was also more rewarding. I left little to PA’s so that I knew what was happening with my patients and did not rely on someone else’s work-up. It may mean less productivity, but it made it easier to keep track of what I was doing. I would also read my note(s) before the case.

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Michael Fidler
July 13, 2018 4:43 pm

I agree with Monica’s comments about interposing mid-level providers into the process. While efficiency is a necessary goal, there is no room for subverting the essential primacy of the surgeon in the responsibility of preventing these kinds of errors.

I note a common theme in the description of these often-horrific error scenarios. In almost every one, there is a surgeon who is too rushed, too anxious to get the next case started, too late to the case, too willing to allow shortcuts to keep moving. This is damning evidence. Our patients expect competence and safety, not a new world speed record.

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