Wrong Site Surgery

 

SurgeryWrong Site Surgery WSS (and wrong site procedures: wrong site anaesthetic, implement fitting, etc) might not be as uncommon as you think. Here is an insight into the problem.
 
Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: ‘which side is the hernia?’
 
Assisting surgeon: ‘I don’t know. I did not see the patient.’
 
Surgeon: ‘Who saw the patient?’
 
Assisting Surgeon: ‘The house surgeon from the previous shift’
 
Surgeon: ‘What does it say in the notes and consent?’
 
Assisting Surgeon: ‘Hernia repair, obviously’
 
Surgeon in anger: ‘Obviously!! But which bloody side?’
 
There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.
 
Surgeon in exasperation: ‘Does anybody know the side?’
 
Medical Student puts her hand up.
 
Surgeon very impatiently: ‘Tell us. What are you waiting for?’
 
Medical student says: ‘I don’t know for sure, but I was standing on the right of the patient’s bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.’
 
Surgeon: ‘Left it is then. Let us get this done’
 
Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.
 
Wrong Site Surgery WSS
(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)
 
Sadly not all patients have lucky days like the above patient. 
 
Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.
 
Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.
 
The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.
 
The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.
 
Solutions
 
It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.
 
Some of the more effective solutions are thought to be:
 
The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.
 
If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.
 
Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.
 
Check lists that include surgical site marking
 
Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected
 
Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.
 
MARK THE SITE
 
This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).
 
Surgeons
Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.
 
Anaesthetists
Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient’s body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.
 
Nurses
 
Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.
 
Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.
 
PATIENTS (and relatives)
Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.
 
Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site
 
EveryonePlease forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.

 About the Author : Dr Makani Hemadri MBBS (Madras) FRCS (Edin) MBA (Leics) works in general surgery in the NHS in England. He is a Fellow of the NHS Institute for Innovation and Improvement; during his fellowship year in 2009 he had the opportunity to interact and learn from the best sources in healthcare improvement such as Intermountain Healthcare and IHI in the USA and Kings Fund in UK. He has held the Leaders for Change Award 2008 from the Health Foundation UK. He is actively engaged in the teaching and training of healthcare delivery improvement.Hemadri blogs in his personal capacity at http://successinhealthcare.blogspot.co.uk/ He can be followed on twitter @HemadriTweets
 
Image Courtesy : Robot Surgery shirt startup weekend dallas sarah worthy – Licensed under Attribution-ShareAlike.
 
Editor’s Note: This is a guest post and the views expressed in the article are solely that of the author. The incidents about patient experiences stated in this blog are highly fictionalised and any resemblance to any person(living or dead)and/or incident is purely co-incidental.
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11 thoughts on “Wrong Site Surgery

  1. Anton Power says:

    Marking the site is a good way to deal with the issue if the mark is not removed. Why not simply improve documentation? Leave a space for a description of the location on record. It’s idiotic human error that can easily be avoided.

  2. Dr Neeraj Nagpal says:

    Lamentable habit of surgeons depending on juniors to do the mundane stuff like preoperative checkup is the most important reason of such errors. Since liability of botched or wrong side surgery lies solely with the operating surgeon and vicariously with hospital the sooner we change our habits the better. Medicine today is to be practiced under court supervision hence margin for error is not there.

    1. Soumyadeep B says:

      It is the small things of life which makes life it is.. In reality it is the what you call ” mundane stuff ” makes the difference between the good and the bad hospital . It is time that better trained juniors are given their due importance

  3. Dr M Chandrashekhar MD says:

    I agree that wrong site surgeries happen. OTs need to have a strong Pre-Op Check List. If it does happen , then the Hospital should do an independent Root Cause Analysis immediately by a Board of Doctors & suggest Corrective & Preventive Actions to be taken. All the findings are documented.

    Medical Director should circulate this findings to all concerned.

    Most Hospitals shove the Incident under the carpet & negotiate with patients.

    1. Soumyadeep B says:

      I also personally belive that such Check Lists are very vital these days of legal medicine. However inspite of the best efforts clinicans and hospital staff often just mark ticks without actually running through them because they consider it to be administrative burden

  4. Dr M Chandrashekhar MD says:

    We need to learn a lesson from Airline Industry– they have ensured that accident rates have gone down drastically by observing rigorous checks– for every flight, the check list is read out between the pilot & co-pilot. I , as a Blood Banker, strictly follow a quality protocol for Blood Transfusions–yet I find errors do occur .

    1. Soumyadeep B says:

      Yes but the real difference lies in the fact that medicine is both subjective as well as objective .. so the tactics might have to be altered to get people to follow the checklists

  5. Hem says:

    There are very good methods such as the WHO safe-surgery checklist and in many locations that has made a difference not only in Wrong Site Surgery but also in reducing infections etc.
    We need to recognise the reality that in many country’s context the WHO checklist is not going to be practiced in its true spirit for a few years to come. In the meanwhile patients must not suffer. Marking the surgical site is one simple, essential and effective way of avoiding wrong site surgery – not perfect, but much better than not doing anything.
    One small step towards better care rather than waiting for ever for that giant collective leap by everyone in healthcare.

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