Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September
In its December, 2008 report, the Florida Board of Medicine addressed four cases of wrong site surgery that had just been reviewed and adjudicated. The Board was concerned by the persistence of this “preventable type of error that we see too often.” The good news was that the incidence of “wrong lens” ophthalmologic cases had diminished. Since these represented 17% of the previous wrong site surgery experience, this was considered an indicator of patient safety program success. Apparently, this is but one piece in what is actually a distressing mosaic of provider performance. Data from the Joint Commission on Accreditation of Health Care Organizations indicates that the incidence of wrong site surgeries is increasing! These were treated as sentinel events and underwent root cause analysis. This is indicative of one of the key characteristics of what should be the quintessential example of preventable error. The relative infrequency of these “never events” makes it difficult to determine efficacy of prevention programs. [1, 2]
Further analysis of the Joint Commission’s assessment indicates that the major problem with wrong site surgery involves orthopedic, urologic, and neurosurgical procedures. [3] Four specific risk factors have been defined and include:
1. Multiple surgeons included in the case.
2. Multiple procedures conducted on the same patient, often by different surgeons or different services
3. Unusual time pressures that result in significant validation steps being rushed or excluded, and
4. Unusual patient characteristics that may undermine or mask definitive assessment of the correct side for surgical intervention.
It is obvious that the glue that ties all four of these factors together is communication. While it seems that something that is as simple as operating on the correct side or site should be a “no brainer,” in reality the enormous press of time and patient volume in modern health care clearly sets lots of traps that can practically guarantee that the system will fail. Review of these traps as defined above demonstrate that the major component in preventing wrong site surgery is effective communication between the responsible surgeon and the patient. It also clearly places the onus of assuring this communication on the surgeon, and nobody else! While the patient may be completely lucid and able to define specific characteristics of a problem during office assessment, that same patient, when partially sedated in the recovery room, may be less alert and even confused. In addition to this obvious core issue of communication there are other specific processes related to each of the four categories above that should minimize or even eliminate potential for wrong site surgery. Michaels et al describe an excellent system for assessment of the existence of an appropriate process for wrong site surgery prevention, as well as recommendations for assessment of staff knowledge of protocols and determination whether the protocols are actually effective.[2] What follows below are suggestions for consideration by the individual who bears ultimate responsibility for care – the surgeon. Each of these ideas is intended to enhance understanding of the basic problem from the perspective of a simple commitment of time and refocusing of effort can avoid personal and professional disaster. Problems 1 and 2: Multiple surgeons and multiple procedures conducted on the patient during the same anesthetic period: These cases are not that uncommon and usually end up as a sequence of events in which a surgeon “comes and goes” while completing his or her own busy schedule. Recommendation: Require that any physician who will touch the patient in any way be known to the patient and discuss with the patient operative plans, risks and complications. Multiple procedures and the sequence of physicians performing them should be listed on the front of the patient’s chart and approved by the patient or appropriate surrogate before initiation of anesthesia. Problem 3: Unusual time pressures that result in significant validation steps being rushed or excluded. Process can be defined as procedures performed according to policy. Policy is intended to optimize process by assuring that procedures are safe, efficacious and efficient. The critical element of this issue has been initiation of the “time out”. As this becomes more inculcated into our surgical culture, the likelihood of this issue remaining a problem will diminish. Recommendation: Insist that everyone in the room pay attention during the “time out”! Problem 4: Unusual patient characteristics may undermine or mask definitive assessment of the correct side for surgical intervention. Risk factors can be categorized in three groups. Those that exist at the time of patient encounter (obesity, diabetes, asthma, etc) are functional comorbidities that must be cataloged on initial evaluation and considered both during patient counseling and for operative risk stratification. In addition to these preexisting factors are care related factors associated with processes and devices used in daily patient care. These include everything from aspiration during placement of a nasogastric tube to urinary tract infection related to bladder catheters. Procedures planned and patient characteristics should predict much of what may be required during the course of care and must be reviewed with the patient before the procedures. The third category of risk factor is often the effect of the first two and relates to physiologic derangement. Sepsis from an infected central line or bladder catheter may be associated with hypotension or hypoxia, thereby producing serious risk to patient survival that is the result of synergistic interaction of pre-existing and procedural factors defined above. Recommendation: All of the above points to the obvious fact that the best strategy for avoidance of problem four is detailed documentation of all relevant patient characteristics. In other words, no unusual “site masking patient characteristics” should ever be a surprise first uncovered in the pre-operative holding area. All of the above underscore just how critical is the requirement that the physician who is ultimately responsible for the surgical intervention be able to meet with the patient “one last time” before induction of sedation and/or anesthesia. He or she must confirm with the patient and, if possible, the patient’s kin what is to be done, where the incision will be, and expected immediate outcome. Unfortunately this translates to an additional time burden on the surgeon. It would be nice to think that the system could be modified in such a manner to guarantee that there would be reliable surrogates for this, but, in reality, the buck does indeed stop with the person holding the knife. If wrong site surgery is to be eliminated, then the physician responsible for initiation of the surgery must make this time investment to confirm the identity of the patient on whom the surgery is being initiated as well as the site of the procedure before the process begins. Anything less is an invitation for disaster and, in the eyes of the Florida Board of Medicine a prescription for avoidable catastrophe. It is indeed a catastrophe for the patient who bears the brunt of incorrect surgery, for the physician who bears the guilt of negligence, and for society, which must endure yet another preventable adverse outcome from the professionals in whom it places its highest hopes and trust. 1. Kwaan, M.R., D.M. Studdert, M.J. Zinner, and A.A. Gawande, Incidence, patterns, and prevention of wrongsite surgery. Arch Surg, 2006. 141(4): p. 353-7; discussion 357-8. 2. Michaels, R.K., M.A. Makary, Y. Dahab, F.J. Frassica, E. Heitmiller, L.C. Rowen, R. Crotreau, H. Brem, and P.J. Pronovost, Achieving the National Quality Forum’s “Never Events”: prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg, 2007. 245 (4): p. 526-32. 3. JCAHO. Sentinel Event Alert. A follow-up review of wrong site surgery. Report No.24. Available at: http:// www.jcaho.org 2001 [cited.
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