Wrong site surgery and anaesthesia.

1. Wahid Altaf

2. 73 year old female had witnessed collapse at around
2200hrs.
Brought in by ambulance to primary hospital at
2300hrs.
Glasgow coma scale of 6/15, hypertensive,
left hemiplegia.
Patient airway secured, intubated, ventilated by
accident emergency team and transferred for CT Scan
head.

4. Scans reviewed in view of clinical scenario.
Patient accepted and plan for Burr hole evacuation of
subdural hematoma.
Anesthetic team called in and patient handed over
with a plan to transfer.
Transferred by anesthetic team in ambulance at
around 0300 hrs.

5. Received patient in operating theatre at 0400 hrs.
Anesthetic, Neurosurgical, Nursing team present at
handover.
Transfer letter with CT scan head on CD made
available.

6. Patient identified and proposed surgical plan
confirmed.
Consent sought from next of kin.
Patient placed for surgical procedure with left side of
head up by neurosurgical fellow.
Head shaved by neurosurgical SHO.
Two Burr holes made by Neurosurgical SpR.

9. Everyone in theatre stunned.

10. Surgical consultant informed.
Two more burr holes made.
Hematoma evacuated.
Patient transferred to ICU intubated and ventilated.
Family informed.
Patient extubated after seven days with reasonable
recovery.

11. Patient sustained a major, preventable error, which
had minimal impact on the outcome.
It likely did, however, have a significant impact on the
psychological comfort and confidence of patient’s
family and operating team.

12. Surgery performed on wrong side or site of body,
wrong surgical procedure performed and surgery
performed on wrong patient.
Incidence 40 times a week in hospitals and clinics in
USA consistent with 1300 to 2700 cases of wrong site
procedures per year.

13. Orthopedic/Podiatric 41%
General Surgery 20%
Neurosurgery 14%
Urology 11%
Maxillofacial, cardiovascular, otolaryngology and
ophthalmolgy 14%.

14. Human Factors in Safety
(30-20%)
Technical
Factors
Accident
Causation
(70 -80%)
Human
Factors
=
Organisational /
Safety
Culture
+
Operator
Behaviour

15. System factors
Institutional controls/formal system
Lack of checklist
Reliance solely on surgeon.
unusual time pressure
pressure to reduce pre-op prep time
Unavailability of information

16. Process factors
Inadequate pt assessment
Inadequate care planning
Inadequate medical record review
Miscommunication among team members
Failure to include patient and family when
identifying correct site.
Failure to mark the correct operation site.
Failure to recheck pt information before starting
the operation.

17. Can be devastating for patient and the operating
team.

18. Preoperative verification
Sign in
Time out
Sign out

19. 1

20. Better verification process.
Marking of surgical site by surgeon responsible for
surgery.
Team briefing.
Time out like national anthem.
Necessity of displaying relevant imaging.

21. Primary responsibility relies on operating surgeon.
Individual professional responsibility of
Anesthetist
Scrub/Circulating/Anesthetic nurse.

22. Process relying on surgeon and surgical memory is
doomed to ultimate failure……..
Don’t assume responsibility as we are equally
responsible……..