Wrong-site surgery: We're not doing all that we can
Dramatic wrong organ error shows there is still much work to be done
The error was as dramatic as it was unimaginable: Surgeons at Methodist Hospital in St. Louis Park, MN, recently removed the wrong kidney from a patient with kidney cancer. Hospital officials in local media interviews called it a "tragic medical error," and few would disagree, but it was also a dramatic reminder for quality and patient safety professionals that preventing wrong-site surgeries remains a major challenge.
Of particular interest was the fact that the local media reported the original error occurred in the charting. Still, say patient safety experts, in an error such as this the blame cannot be placed on a single process.
"I am highly skeptical of the concept that this was 'just a charting error,'" says Leah Binder, MA, MGA, CEO of The Leapfrog Group. "An error of this magnitude requires several errors, and several [missed] checks and balances. While the odds are unlikely they will find 12 different points where this could have been caught and they missed them all, there is no way you could say it was one error."
Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission, agrees. "The [Joint Commission's] universal protocol [for preventing wrong-site, wrong-procedure, wrong-person surgery] has three steps; everyone focuses on the last two, but the first is the pre-operative verification process," he notes. "This should begin as soon as the patient is booked and repeated every time the patient goes through pre-operative procedures to verify the correct site, the correct patient, the correct side."
Although the universal protocol has been in place for several years, Angood notes, "the number of reported wrong-site events remains higher than we would want." In fact, he adds, Minnesota has a mandated state reporting system in place, and in its experience about half of the reported "never" events are wrong-site surgery and/or retention of foreign bodies. "They follow the universal protocol, but even with that, errors persist," he says.
Both the verification process and the timeout process (step three, occurring immediately before the surgery) state that all relevant medical records, images, and equipment should be checked and assessed prior to starting the procedure, Angood continues. "The universal protocol is designed to stop these errors from happening and [detecting] failure at some point or several points," he observes. (The universal protocol will be undergoing some significant changes soon.)
"In such breakdowns human error is the one given — you will have it," adds Binder. "Several stages must be checked before the patient goes into surgery, and you have to build that in [to your processes] and enforce the protocol, which is extraordinarily difficult to do. Anyone who thinks it is easy has never worked in a hospital."
Begin with the physician
Hospitals with in-depth processes designed to prevent such errors begin as early in the care process as they can. "Our process starts with the physician's office — with the surgeon booking the procedure," says Allynn Petersen, MS, RN, CNOR, administrative director, surgical services at William Beaumont Hospital in Royal Oak, MI. "We are mainly a private practice academic institution, and when the surgeon books the case in our scheduling office, we have no other alternative but to assume they are boarding the correct patient."
However, she adds, one of the checks her facility has put in place is to add pre-screening nurses who actually confirm the site — including laterality — and the procedure with the patient. "That is done sometimes up to two weeks ahead of the surgery," she says. "And we have caught some laterality issues with that process."
Once the error is caught, the anesthesiologist and surgeon are notified and the operation is re-scheduled.
Involvement of the patient is an important part of the universal protocol. In fact, The Joint Commission has enumerated a list of implementation expectations for the protocol, and in the pre-operative verification process those expectations include verification of the correct person, procedure and site:
- "With the patient involved, awake and aware, if possible;"
- "Before the patient leaves the preoperative area or enters the procedure/surgical room."
- "From the time of admission to when the patient is examined by a nurse, and the anesthesiologist, there needs to be reinforcement of what the procedure point is to be and where the problem is," notes Binder. "Surgeons should be examining and re-examining the imaging and the diagnosis over and over, like a military drill. You need to read the chart and really, really confirm with the nurse and/or the anesthesiologist every aspect — you have to follow certain protocols to make sure you have done what is required to prevent never events."
However, says Petersen, things are not always so cut and dried. "Many of our physicians also bring their charts from the office, especially when they have more than one patient that day, and they have that as a resource," she says. "If there are X-rays from radiology, they do have to have them available, but not all procedures require them." For example, she points out, "we use them in reference to spinal surgery for location, like which disc you are removing." In terms of a kidney removal, she adds, "I don't know that they would."
"The surgeon should read the chart and the imaging — actually look at it," Binder counters. "If there are any questions, they should ask — and the same with the nurses and others on the team; there are many stages at which this could have been caught."
In order to do this, she adds, you need a healthy environment of communications. "It has got to be acceptable for the nurse to blow the whistle and say, 'This can't be right,'" says Binder. "You must create an environment where mistakes can be addressed and prevented."
Still, says Petersen, "Once it was scheduled I can see where they had a difficult time stopping this. To me, this almost started way back when — they could have told the patient the wrong side, or had a mistaken reading of an X-ray, which led to the 'charting error.'"
Even though it is possible for a patient to be given bad information, Petersen says, "I do like our piece of verification with the patient — that's always a good one."
She also notes that under the universal protocol, the surgeon would have to mark the site the patient agreed on. "We involve the patient and review what's on the schedule with [the] consent [form]," she says. "If they all agree it is the left kidney and the doc agrees, you're kind of done." Nonetheless, she concedes, it's still possible that all that might have taken place in this case. "That is kind of scary," she shares.
Set the right tone
Binder says that to minimize errors such as these "we have to make safety that No. 1 priority — and to do that, it needs to be on the CEO's list of No. 1 priorities. (To learn more about garnering CEO support, see our article about "getting boards on board" on pg. 54.)
"Then, when you have done that, you have to look at your systems and put in place those processes and systems that will check against human errors." Leapfrog's own survey, she adds, "helps hospitals check on their own safety practices."
Targeted collaborative initiatives are also important, says Petersen. "For example, we are currently involved in the Keystone OR project," she notes, which involves the Michigan Hospital Association and Johns Hopkins. "In that program, we have a briefing and debriefing process, where the team members participate in identification of the patient, adding anything else that might pertain to that patient such as whether it might be a particularly difficult procedure, whether certain instrumentation is available, or how much blood we have," she notes.
Binder offers this final word of caution. "Something that is written on a chart is not the final word on diagnosis," she says. "Even if the radiologist wrote a diagnosis on the chart, it is helpful for others to look at the imaging. So, for example, if the chart says left kidney but the X-rays seem to show it is the right one, somebody should speak up and say that doesn't look right. You should have in place as many ways to check these things as possible, and team members should be held to the highest level of accountability."
[For more information, contact:
Peter Angood, MD, Vice President and Chief Patient Safety Officer, The Joint Commission, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.
Leah Binder, MA, MGA, CEO, The Leapfrog Group, c/o Academy Health, 1150 17th Street NW, Suite 600, Washington DC 20036. Phone: (202) 292-6713. Fax: (202) 292-6813. E-mail: [email protected].
Allynn Petersen, MS, RN, CNOR, Administrative Director, Surgical Services, William Beaumont Hospital, 3601 W. 13 Mile Road, Royal Oak, MI 48073. Phone: (248) 898-7221.]
The error was as dramatic as it was unimaginable: Surgeons at Methodist Hospital in St. Louis Park, MN, recently removed the wrong kidney from a patient with kidney cancer.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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