Spotlight Case October 2003 Hemivulvectomy: Wrong Side Removed

2 Source and Credits This presentation is based on the Oct AHRQ WebM&M Spotlight Case in OB/GYN See the full article at CME credit is available through the Web site –Commentary by: Charles Vincent, PhD, Imperial College School of Science, Technology, and Medicine –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Tracy Minichiello, MD –Managing Editor: Erin Hartman, MS

3 Objectives At the conclusion of this educational activity, participants should be able to: List factors contributing to wrong site surgery Understand key components of the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surgery Appreciate the importance of communication across an authority gradient Understand the challenges and consequences of disclosing medical errors

4 Case: Wrong Side Surgery A 33-year-old woman with microinvasive vulvar carcinoma was admitted for a unilateral hemivulvectomy. After the patient was intubated for general anesthesia, the trainee reviewed her chart and noted that the positive biopsy was from the left side. As the trainee prepared to make an incision on the left side of the vulva, the attending surgeon stopped him and redirected him to the right side.

5 The trainee informed the attending that he had just reviewed the chart and learned that the positive biopsy had come from the left side. The attending physician informed the trainee that he himself had performed the biopsies and recalled that they were taken from the right side. The trainee complied and performed a right hemivulvectomy. Case (cont.): Wrong Side Surgery

6 The next day, the Chief of Pathology called the trainee to inquire about the case. The specimen he received was labeled “right hemivulvectomy” and did not reveal any evidence of cancer; whereas the pre-operative biopsies the pathologist had reviewed (labeled “left vulvar biopsy”) had been positive. He wondered if there had been a labeling error. Case (cont.): Wrong Side Surgery

7 Wrong Side Surgery: Scope of the Problem JCAHO: 114 wrong site surgeries from 1152 sentinel events (January 1995-March 2001) Survey of hand surgeons –20% operated on wrong side at least once –16% experienced a ‘near miss’ Full extent unknown and likely under-reported Shojania KG, et al. Making Health Care Safer Meinberg EG, et al. J Bone Joint Surg Am. 2003;85:193-7.

8 Wrong Side Surgery: Contributing Factors Inadequate patient assessment Incomplete medical record review Poor handwriting Reliance on surgeon alone to identify site Poor communication among OR team Vincent C, et al. BMJ. 2000;320:

9 Multiple procedures performed on same patient Time pressure Lack of clear policies Shojania KG, et al. Making Health Care Safer Wrong Side Surgery: Contributing Factors

10 What Went Wrong in this Case? Accuracy of site not confirmed by OR team –Poor team communication Reliance on recall rather than documented evidence to determine side of surgery –People can express a high degree of confidence in inaccurate “new memories” Cohen G. Memory in the real world

11 Communication Across an Authority Gradient A survey asked whether junior staff members should be free to question decisions made by senior staff members Responses differed by profession (% “yes”): –Airline pilot response: 97% –Surgeon response: 55% Sexton JB, et al. BMJ. 2000;320:745-9.

12 Believe that junior staff should be free to question senior staff decisions Sexton JB, et al. BMJ. 2000;320:745-9.

13 Case (cont.): Wrong Side Surgery The trainee informed the pathologist that the right side had been removed, and then informed the attending surgeon about the alleged error. The surgeon denied that any error had been made; he insisted that the original biopsies had been mislabeled. The surgeon did not inform the patient of the error.

14 Case (cont.): Wrong Side Surgery When the patient returned for routine follow- up, the surgeon performed a vulvar colposcopy and biopsied the left side. Microinvasive cancer was noted in the biopsies. Shortly thereafter, the patient underwent a second hemivulvectomy to treat her vulvar cancer.

15 Disclosure of Medical Errors Consider impact of disclosure vs. non- disclosure Error disclosure must be accompanied by offers of long term support, remedial treatment, and continuing relationship with patient and family

16 Disclosure of Medical Errors: Challenges for the Physician Loss of patient’s trust Effect on reputation Fear of litigation Difficulties communicating about the error with the patient Wu AW. BMJ. 2000;320:726-7.

17 Disclosure of Medical Errors: Patient Preferences Patients who have not experienced error report that in event of harmful error they would desire full disclosure Patients who have been harmed report a need for apology, explanation, and assurance of prevention of future events Gallagher TH, et al. JAMA. 2003;289: Vincent C, et al. Lancet. 1994;343:

18 Web-based Resources JCAHO. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. fety/universal+protocol/wss_universal+protocol.htm fety/universal+protocol/wss_universal+protocol.htm Department of Veterans Affairs. Ensuring correct surgery; VHA Directive American Academy of Orthopaedic Surgeons. Advisory statement on wrong site surgery.

19 Web-based Resources (cont.) American Academy of Orthopaedic Surgeons. Report of the task force on wrong-site surgery. North American Spine Society. Prevention of wrong- site surgery: sign, mark & x-ray (SMaX). Association of Operating Room Nurses. AORN position statement on correct site surgery.

20 Take-Home Points Wrong site surgery is a potentially devastating and completely avoidable error Implementation of the Universal Protocol can help minimize errors Team communication is critical Efforts must be made to eliminate barriers to communication across authority gradients

21 Take-Home Points Disclosure of medical errors is challenging for both physicians and patients Physicians must be aware of the potential consequences of disclosure and be prepared to deal with them