Telling right from wrong
Mr B, a 56-year-old retired builder, consulted his GP, Dr R, complaining of right-sided scrotal discomfort, of several months duration. He had no previous urological history, and the preceding year had taken early retirement. On examination, the GP noted a small epididymal cyst, which was tender to palpation.
The testes themselves appeared normal, and there was no evidence of any abnormality in the left hemiscrotum. Dr R reassured Mr B that the likely diagnosis was a benign cyst, but in view of the discomfort he was experiencing, referred him to Mr Y, a consultant urologist.
Mr B attended Mr Y’s outpatient clinic, where he was seen and examined by Mr T, Mr Y’s registrar.
The referral letter written by Dr R stated that Mr B’s discomfort was on the right side of the scrotum, and on examination Mr T felt a small lump, which he thought was probably an epididymal cyst. He considered whether Mr B should undergo a scrotal ultrasound to confirm the diagnosis, but decided against it. He listed Mr B for excision of his epididymal cyst, stating in the case notes that it was on the right side.
Mr B attended for his procedure as a day case. He was seen by Dr P, SHO in urology, who consented him for excision of an epididymal cyst.
Although the notes were available, he did not read them, nor did he mark the affected side or state it on the consent form. Neither did he perform a physical examination of Mr B’s scrotum. He did read the printed theatre list, however, which stated that the cyst was left-sided.
Preoperatively, Mr Y also spoke briefly to Mr B. He consulted the theatre list to check the side, but did not examine Mr B prior to induction of anaesthesia. Mr B therefore underwent an exploration of his left hemiscrotum. At operation, Mr Y was surprised that the cyst was not more obvious to the naked eye.
However, on palpation a small thickened area was found in the epididymis, and this was excised. Mr B made an unremarkable recovery from his anaesthetic and was discharged home.
A fortnight later, Mr B attended his GP’s surgery, again complaining of right-sided scrotal discomfort. Dr R examined his scrotum, and was surprised to find a palpable cyst in the right epididymis, particularly as he knew Mr B had very recently had surgery for removal of this cyst.
Further examination revealed a scar on the left hemiscrotum, consistent with the surgery Mr B had recently undergone.
The case was reviewed by a urology expert, who was critical of the consent process on a number of grounds.
There was criticism of the way in which consent was taken by the SHO, who did not take any steps to check which side the cyst was on, ie, he did not read the notes, perform a physical examination, or mark the affected side. Nor did he state the side on the consent form.
Mr Y was similarly criticised, although he did say that he believed the patient had indicated to him that the cyst was on the left. Nevertheless, despite being the operating surgeon he had not examined the patient himself prior to undertaking the operation.
Fortunately for Mr B there were no long-term sequalae. He subsequently underwent excision of his right-sided cyst, with resolution of his symptoms, and the case was later settled for a low sum.
Wrong-site surgery is not common, but it is a regular problem.
Paperwork should be double-checked prior to surgery and any inconsistencies investigated.
Ideally consent should be taken by the operating surgeon. If it is delegated to another doctor that doctor must be fully conversant with the risks and benefits of the procedure.
Where there is the possibility of confusing the side of a procedure, the appropriate side should be marked, again ideally by the operating surgeon.
Extra care should be taken with the consent process if there is any doubt over whether a patient is competent to give consent.
The operating surgeon is responsible for ensuring that appropriate consent has been taken and that the right operation is being performed before proceeding.
General Medical Council (UK) guidance on seeking consent, available online at www.gmc-uk.org.
The National Patient Safety Agency and the Royal College of Surgeons of England Guidance produced a patient safety alert on correct site surgery in 2005. It is available online at www.npsa.nhs.uk.
The Association for Perioperative Practice has produced a poster on correct site surgery, which stresses the importance of a team-based approach to the problem. www.afpp.org.uk