1. HealthGov Conference 10-11 December 2007 “CASE STUDY – REMOVAL OF THE WRONG BREAST” The uneasy balance between systematic/individual responsibility Helen Turnbull Legal Manager, Disciplinary Services 10-11 December 2007

2. CASE STUDY REMOVAL OF THE WRONG BREAST History GP found lump in Left breast. Referred for investigation. Bilateral Mammogram & Ultrasound Report - Irregular 14mm lesion lying at the 3 o’clock position 5cm from Left nipple. Primary breast cancer.

3. Referred to Surgeon Surgeon found palpable 2cm lump at the approx 2 o’clock position some distance from the Left nipple. Opinion – Highly suspicious of malignancy Surgeon took a fine needle aspiration biopsy (FNAB); provided National Breast Cancer Centre material; drew illustrations; discussed options/risks/complications. FNAB confirmed the malignancy. Decision - Mastectomy. CASE STUDY – REMOVAL OF THE WRONG BREAST

4. Mistakes Mistake 1 Admission Request/Consent Form. Surgeon wrote ® rather than L Mistake 2 Surgeon did not have patient’s medical records before him when filling out Admission Request/Consent Form. Mistake 3 Surgeon did not have own medical records in operating theatre. CASE STUDY – REMOVAL OF THE WRONG BREAST

5. Result The patient’s Right breast was removed instead of the Left. CASE STUDY – REMOVAL OF THE WRONG BREAST

6. Swiss Cheese Model 78yr old patient suffering from severe dementia and could only speak Russian 1 st consultation accompanied by her daughter 1 CASE STUDY – REMOVAL OF THE WRONG BREAST

7. Swiss Cheese Model (cont’d) Decided that unfair on patient to return to surgeon’s rooms so the daughter agreed to attend to pick up the Admission Request Form. Son-in-Law instead attended during a particularly busy morning session. Surgeon filled out the Admission Form at the receptionist desk in between appointments without consulting his clinical records. 2 CASE STUDY – REMOVAL OF THE WRONG BREAST

8. Swiss Cheese Model (cont’d) Patient did not attend pre-admission clinic 3 CASE STUDY – REMOVAL OF THE WRONG BREAST

9. Swiss Cheese Model (cont’d) No formal admission clerked by a RMO 4 CASE STUDY – REMOVAL OF THE WRONG BREAST

10. Swiss Cheese Model (cont’d) Entry made in the nursing notes in the hospital records was for a ® mastectomy nurse copied the Admission Form. Nursing home details faxed to hospital were not attached to hospital records 5 CASE STUDY – REMOVAL OF THE WRONG BREAST

11. Swiss Cheese Model (cont’d) Daughter did not accompany patient to operating theatre No formal handover by ward nurse to theatre Surgeon did not conduct physical examination X-rays were not in the theatre 6 CASE STUDY – REMOVAL OF THE WRONG BREAST

12. Swiss Cheese Model (cont’d) WRONG BREAST REMOVED Normal Registrar was running late, another Registrar filled in. Patient was already draped with ® breast exposed. Registrar was asked to do surgery. Registrar assumed all cross checks had been done. CASE STUDY – REMOVAL OF THE WRONG BREAST

14. Surgeon’s Responsibility At all times the Surgeon accepted full responsibility for the error. Spoke frankly to the family and sincerely apologised. CASE STUDY – REMOVAL OF THE WRONG BREAST

15. Hospital’s Responsibility Open honest and timely investigation by the hospital. CASE STUDY – REMOVAL OF THE WRONG BREAST

16. Changes to the Hospital Practice Improved Consent Forms  returned to VMO if incomplete  procedure, side & site printed Special Needs patients  alert on admission Patients not attending pre-admission clinic to have mandatory medical admission. CASE STUDY – REMOVAL OF THE WRONG BREAST

17. Changes to the Hospital Practice (cont’d) Improved checking system at all points of entry. Correct side & site check list  College  Department of Health JMO/RMO to ensure imaging/pathology in theatre. CASE STUDY – REMOVAL OF THE WRONG BREAST

18. Changes to the Surgeon’s Practice Doctor’s own notes present when completing Admission Form. Doctor’s own notes in theatre. Doctor’s independent confirmation in theatre:  Phoning the daughter  Examining the patient after sedation  Consulting admitting officers  Ensuring x-rays in theatre CASE STUDY – REMOVAL OF THE WRONG BREAST

19. Accountability/Punishment Redesigning systems to reduce error Annals of Internal Medicine 17 June 2003 CASE STUDY – REMOVAL OF THE WRONG BREAST

20. Redesigning systems to reduce error Accountability/Punishment

21. Uneasy balance between systems error and individual responsibility “Was everything as safe as it could have been?” She asks quietly Open disclosure. Local climate of psychological safety. Leadership. Look beyond the individual error. CASE STUDY – REMOVAL OF THE WRONG BREAST

22. THE END