0 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.