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Who’s changed my list?

01 January 2008

Ms D, a 41-year-old secretary, experienced worsening pain and paraesthesia in her right hand over the course of a year. Her GP referred her to a consultant orthopaedic surgeon, Mr S, for surgical treatment of her carpal tunnel syndrome.

Before Ms D was admitted for elective surgery, Mr S asked her to choose between a general and local anaesthetic whilst he was obtaining consent on his morning ward round. Ms D opted for general anaesthesia.

Mr S put Ms D third on his afternoon list, after Mrs C, who had also chosen to have a general anaesthetic for the surgical treatment of her carpal tunnel syndrome in her left wrist. Mr S planned to treat Ms D’s symptoms with endoscopic surgery and Mrs C’s with open release surgery.

After Mr S’s ward round, Mrs C was removed from the afternoon list, apparently because she had eaten a slice of cake. An F2 doctor on the ward, Dr P, rang the theatre to rearrange the list order and have the new list printed for Mr S in theatre, but it is not clear whether this new list was shown to the theatre staff.

Instead of Mrs C, Ms D came up to the operating theatre as Mr S’s second patient. Once Ms D was anaesthetised and prepped as per Mr S’s instructions, Mr S started the open release surgery on Ms D’s left wrist.

Five minutes into the surgery, the trainee assisting realised the mistake and informed Mr S. Mr S closed the wound and performed the correct endoscopic surgery on Ms D’s right wrist.

On waking from her GA, Ms D was met by Mr S, who informed her of the mix-up and apologised profusely before completing a significant event/ clinical incident form.

Ms D recovered but was left with a painful and unsightly scar on her left wrist. She made a claim against Mr S for performing the operation on the wrong arm.

Expert opinion

The case was settled for a low sum.

Learning points

  • The system in place at the hospital was criticised – there was no clear policy or procedure in place at the time. It was not standard procedure, for example, to mark the arms of patients.
  • Never operate on the list; operate on the patient. Last minute changes to operating lists are very common and can be for a variety of reasons. Mr S or Mr A should have marked the correct limb prior to surgery and checked the patient details on the identity band, operating list and with Ms D before she was anaesthetised.
  • Better communication between colleagues would also have helped in this case. The trainee could have spoken directly to Mr S about the unplanned list change.
  • Before surgery commences: the surgical, anaesthetic and theatre teams involved should verbally confirm (in each other’s presence) the presence of the correct patient, the marking of the correct site and the procedure to be performed.

Further information

While wrong-site surgery is rare, its incidence seems to be on the rise.

In 2005–2006 there were 40 claims of wrong-site surgery reported to the NHS Litigation Authority (NHSLA) at a cost of over £1 million. This is up from 35 claims in 2004–2005 costing just over £600,000 and 27 claims in 2003–2004 costing just under £500,000.

In 2005, the UK’s National Patient Safety Agency (NPSA) and The Royal College of Surgeons of England published “correct site surgery” guidelines including a “correct site surgery” verification checklist.

In July 2007 the NPSA also published guidelines for standardising the wristbands in the NHS. The NPSA found that more than 10% of the incidents where patients were mismatched to their care were related to patient wristbands. It has therefore developed a standard wristband design to be used in all NHS organisations by July 2009.

There are several other existing site-verification protocols used globally, including the 2003 Universal Protocol for Wrong Site, Wrong Procedure, Wrong Person Surgery, published by United States-based health care assessment organisation, the Joint Commission (previously known as the Joint Commission on Accreditation of Healthcare Organizations, JCAHO).

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