Recommendations offered to avoid wrong-site surgery in patients with multiple procedures

Issue: September 2010

ByMichael Masini, MD

B. Sonny Bal

Lawrence H. Brenner

It has been estimated that one out of four orthopedic surgeons who have been in practice for more than 25 years will have performed at least one wrong-site surgery. During the period from 1998 to 2001, 114 cases of wrong-site surgery were reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); this figure probably grossly underestimates the actual number of such cases. Public attention has been increasingly focused on this issue; while rare, wrong site surgeries are regarded as indefensible events that should never occur.

Universal protocol

In 2004, the JCAHO adopted the elimination of errors in surgical site, patient identification, and accuracy of procedure as a National Patient Safety Goal. The so-called “Universal Protocol” was implemented as a tool to prevent such errors. The protocol tool consisted of deliberate preoperative verification of the patient and surgical site, surgical-site marking by the surgeon, and operative team “time-outs” for all surgical procedures. The universal protocol tool involves the entire surgical team and includes predefined steps which take place both outside and within the operative suite, much like a preflight checklist.

The actual surgery is supposed to start only after a final pre-incision time-out check which gives team members one more chance to verify the patient’s identity, the nature of the procedure to be performed and the site — usually left or right — where the procedure is to be performed, as confirmed by a comparison to the signed consent.

Poor compliance

Analysis of outcomes after the adoption of the universal protocol has shown that errors relating to the surgical site still occur, even with the patient and nature of the procedure performed being identified. One study, by Johnston and colleagues, reported poor surgeon compliance as one possible cause of these errors. The study did not identify any wrong-site misadventures, but found that surgical-site markings and proper time-out procedural checklists were completed in only 70% of the cases studied. Of the remaining cases, in 22% either proper surgical-site markings or a credible time-out was performed, but not both. Finally, in about 7.4% of the cases, both the time-out and the surgical-site marking were skipped. The investigators remarked that complacence was common among the surgical teams investigated, and that orthopedic surgeons should be encouraged to abide by the universal protocol guidelines every time they operate.

In a related study, Wong and colleagues reported on an American Academy of Orthopaedic Surgeons (AAOS) membership survey that was designed to elicit the incidence of wrong-site surgery (See Top medical mistakes in orthopedics include equipment, communication errors). This survey was done in 2005, and of the 5,540 AAOS fellows to whom the survey was mailed, 917 responded (response rate of 16.6%), with 53% of respondents having observed a medical error in the previous 6 months. Of the wrong-site surgeries reported, most involved the wrong side, while others involved the wrong digit or toe on the correct side, or the wrong procedure, or the wrong patient. The most frequent anatomic locations for wrong-site surgery were the knee and the hand, followed by the foot/ankle, femur and spine.

Clearly, wrong-site surgery persists, despite vigorous national efforts to eliminate this problem. The universal protocol may have reduced the incidence of these errors, but has failed to eliminate them entirely.

Most studies identify surgeon complacence and/or poor surgical team communication as a major cause of errors. My team encountered a case, described below, that suggests possible changes to the universal protocol, especially for those orthopedic specialties that frequently perform procedures on multiple sites during the same operative setting.

Case presentation

A 67-year-old man was wheeled into the operating room for a right hip replacement and a right knee injection. The right thigh was marked in the preoperative area by the surgeon, and the consent was reviewed in the operating room to correctly identify the right hip. The patient was brought to the room by the circulating nurse and nurse anesthetist; the latter placed an epidural catheter for anesthesia. A proper check-in procedure was done upon entering the operating room with a physician assistant present. Shortly after insertion of the Foley catheter, the physician assistant left the operating room.

While the patient was being prepped for hip surgery, a different physician assistant checked the signed consent, misinterpreted “LT” for “RT” and injected the incorrect, left knee joint. The error was discovered, conveyed to the patient in the recovery room, and the correct, right knee was then injected.

Analysis

The above adverse event was reported to the appropriate hospital committee, and a thorough root-cause analysis investigation was conducted, the findings of which showed that:

The consent was not as legible as it should have been, and the word “right” was not written out completely. Instead, the abbreviation “RT” was used;
The hip was marked by the surgeon, but the knee was not; and
The knee injection, considered much more benign than a total hip, was done without a separate time-out protocol.

From the above analysis, it was clear that the universal protocol, as set, failed to address certain variables; one being multiple procedures scheduled under the same anesthetic, with different surgical sites involved.

The issue of injections being regarded as surgical procedures has interested me. Injections into knee joints are commonly performed in orthopedic offices, and the injection sites are never marked. In contrast, when such injections are done in a hospital operating room, the injection is deemed a “procedure” that requires a consent, and marking of the surgical site. It is not uncommon for patients with bilateral knee arthritis, for example, to ask for an injection under anesthesia into the unoperated knee, while undergoing arthroplasty in the other knee.

Formal time-out checklists are rarely done for knee injections, especially separate from the concomitant major procedure, especially when these injections are done incidental to an arthroplasty of another major joint. Most operative consent forms only have a couple of lines worth of space for listing the principal procedure and rarely have any space to list other, ancillary, minor procedures such as an injection into another joint.

Recommendations

Multiple procedures at different sites, scheduled under the same anesthetic thus have the potential to create confusion, even if the universal protocol guidelines are followed. My experience and that of my group offers the following recommendations that can help prevent wrong-site events in such situations; hopefully these are of value to readers of this column:

The operative consent should spell out “right” and “left,” rather than “L,” “R,” “LT,” or “RT,” or similar abbreviations that could contribute to errors;
Each procedure, no matter how trivial, easy, or seemingly minor, should be numbered separately on the consent form, in legible print;
Every operative site should be marked by the surgeon; and
Surgical site markings should include abbreviations or words that help the surgeon identify what is to be done at that site, ie, INJ (injection), vs. TKA, (total knee replacement), REV (revision arthroplasty) and PK or UKA (partial or unicompartmental arthroplasty);

l A time-out should be performed before each procedure, and the surgical consent form should be checked off before individual procedures by the circulating nurse to avoid errors and to ensure that each of the consented procedures has been performed correctly, and on the correct limb.

It is further suggested that each orthopedic specialty society should determine abbreviations that are appropriate, and might avoid confusion. For example, REV-TKA should be used instead of TKR because TKR can mean both “total knee replacement” and “total knee revision.” PK or UKA should be used to designate a unicompartmental knee arthroplasty, rather than UNI, which can be confused with INJ, or injection. “Total Knee Replacement” should be used on the consent form instead of “Total Knee Arthroplasty” because “Arthroplasty” could be confused with ”Arthroscopy” if a reviewer were to hurriedly look at someone else’s handwriting. In summary, the consent and markings should be clear, standardized, and unmistakable when multiple procedures are being performed.

The aim of the above offered suggestions is to prevent wrong-site surgeries that continue to occur at a finite rate, despite the institution of the universal protocol guidelines. Wrong-site operations are clearly indefensible in malpractice litigation; these errors occur in private, academic and government hospitals, and can happen to surgeons of every age and experience. The goal should be to eliminate them entirely from the surgical community; your suggestions and tips in this important matter are welcome.

B. Sonny Bal, MD, JD, MBA, is associate professor of hip and knee replacement in the department of orthopedic surgery, University of Missouri School of Medicine.

Lawrence H. Brenner, JD, is on the faculties of orthopedics at Yale University and the University of Southern California and practices in Chapel Hill, N.C. Address all correspondence to Brenner at lb@lawrencebrennerlaw.com.