AUGUST 19, 2013
Wrong-site surgery and checklist (non)compliance

This week, we learned of two California hospitals which were cited by the state for wrong site surgery.

At one hospital, a skin incision was made in the right groin of a patient who was to have had a left orchiectomy. Fortunately the error was discovered, and the skin was closed. The correct testicle was removed. To his credit, the surgeon told the patient and his wife what happened immediately after the operation.

An investigation found that the patient's groin had not been marked. The time out did not prevent the error because the OR team did not verify the operative site as the protocol mandates. In other words, they had gone through the motions.

The hospital was fined $75,000.

The other California case did not turn out as well. Instead of removing a cancerous left kidney, surgeons did a right nephrectomy. The error was not discovered until the pathology report was reviewed. A number of assumptions and misunderstandings contributed to this error for which the hospital was fined $100,000.

Both hospitals made the usual system and protocol corrections that are precipitated by any state investigation. But these were human errors and will likely happen again. The existing policies were adequate. They simply were not followed.

Another case that occurred in July but recently just surfaced is from Florida. A surgeon performed a vascular procedure on the wrong leg. Apparently, a nurse anesthetist noticed the error during the case and spoke up, but the surgeon didn't stop. He finished the wrong leg and then did the correct leg too.

When the patient awoke, the surgeon asked her to sign a consent form for the wrong leg and told her that she had needed that surgery anyway.

The hospital failed to report the error for two weeks.

In the Orlando Sentinel article, a hospital spokesman said, "We have policies in place, and training in place, but the system broke down because of the human element." I think he was admitting that the incorrect procedure was the result of a human error, but I'm not sure.

A state inspection found many issues, and the hospital has been threatened with termination of its Medicare and Medicaid provider agreement.


It appears that operating room checklists, for all their promise, are not working out as well as they should.

Two recent papers looking at three distinct hospital settings, have found that checklist use and completeness are less than ideal.

At Scott and White Memorial Hospital in Texas, researchers found that OR checklists were used 94% of the time, but 54% contained inaccurate data and 15% were not fully completed. Compliance with the "time out" portion of the checklist was found in 77.8% of cases.

The paper appeared on line in the Journal of the American College of Surgeons.

In a Medscape report on the study, the senior author was interviewed and said that some of the hospital's surgeons did not "buy in" to the concept.

Dr. Atul Gawande, commenting on the paper, wondered if scrubbing 94% of the time would be acceptable and speculated that using the checklist was not the norm in that institution. Gawande also suggested that one-on-one contact with every surgeon might be the way to improve checklist use.

A paper from the UK published in BMJ Open looked at OR checklists in two hospitals in the UK and one in sub-Saharan Africa. Staff from all three were interviewed extensively.

The authors found that the rate of checklist use was better in the UK hospitals than the one in Africa, but like the Texas study, checklists were not used 100% of the time. Accuracy was also inconsistent. Completeness was noted to be variable especially in Africa, and there were many lapses in performance of checklist components.

An OR nurse in the African hospital said, "Even though training on the checklist was given for surgeons, they dont use it, they dont believe in this bit of paper, because mostly they said, we dont mistake the identity of the patient, it doesnt happen that we get the wrong patient.'"

An anesthetist in the UK said, "Were trying to prevent what are usually rare errors, rare mistakes, you know, the majority of the things on that checklist are done most of the time without the checklist, but every now and then [...] you forget to check if youre operating on the right leg and not the left leg, and thats rare, but on very rare occasions it then leads to a disaster."

What have we learned here?

We have a long way to go until the checklist becomes a real factor in preventing errors.

Surgeons should reflect and admit that this sort of mistake should never occur. Until we accept this and lead the way, these stories will continue to make us all look bad.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at and tweeting as @SkepticScalpel. His blog averages over 1000 page views per day, and he has over 6600 followers on Twitter.

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