How to Operate on the Wrong Site

In a news article about some sanctions that the state of California imposed on certain hospitals for misdeeds, the following summary of one incident appeared. I have added some emphasis in bold.

A six-year-old boy had to undergo a second surgery to remove a growth after a surgeon performed the wrong surgery on his tongue.

“This failure resulted in [the patient] being exposed to the risks of bleeding and infection, and unnecessary exposure to the risks associated with anesthesia that was needed to perform the right procedure,” state documents say.

“The surgeon told investigators that he couldn’t be sure whether a time-out [explanation: a pause in the preoperative routine to ask all members of the OR team if they all agree on who the patient is and what the operation will be], which was said to have transpired according to the hospital’s policies, was ever done.”

“Either time-out was not done or it was done, but I could not recall what procedure was said,” the surgeon told state investigators. The surgeon then said that team members, who should have known the correct procedure, should have asked why there was no specimen of tissue from the removed growth.

Asked whether he examined the patient prior to the surgery, the surgeon replied, “Usually, I don’t examine anybody. In this case, there was no time to do a pre-operative visit. From now on, I need to see the patient prior to surgery.”

The hospital was fined $50,000.

I can’t blame anyone who read that story for wondering just what the hell we are all doing in hospitals today.

The wrong operation, a tongue-tie release, was performed. The surgeon couldn’t recall if a time-out was done. He faulted the staff for not mentioning that no specimen was obtained. He apparently had seen the patient in his office but did not re-examine him on the day of surgery and did not usually do so. It’s not all bad though. He said, “From now on,” he will start seeing the patients before he operates.

The official report cites the hospital for failing to follow its own procedures regarding verification of the type of operation to be performed.

It is basic good practice and common sense to examine every patient again on the day of surgery and reconfirm the nature of the procedure, the correct side and answer any questions the patient or family might have. For example, I have seen lymph nodes that I was asked to biopsy shrink dramatically in the 10-14 days between my office examination and the planned surgery day.

Who obtained consent from the child’s mother? What did the consent form say? Didn’t the circulating nurse or anyone else look at the form to verify what operation was to be done? Don’t the nurses enforce the time-out rule? What was the anesthesiologist doing?

Maybe the fine and the hospital’s “system error” type plan of correction, which entails monitoring 30 time outs per month for an unspecified period of time, will prevent this from happening again.

I doubt it.

See how easy it is to operate on the wrong site? People can defeat any system correction plan.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5,600 followers on Twitter.