As a board-certified neurosurgeon in practice for nearly 30 years, I have served as chair of the neurosurgery section at a major medical center and as vice chair of the entire surgery department for a number of years. As vice chair of the surgery department, I was also chair of the department’s Quality Assurance Committee, and I additionally served as a sitting member of that committee for eight years.
During my tenure in these positions, I was faced with several instances of medical errors involving colleagues, including wrong-site surgery. I listened to surgeons describe how their errors occurred and always found myself very unsympathetic. I could not imagine how conscientious surgeons could make such errors and could not, in my wildest dreams, imagine it happening to me. I am one of those compulsive surgeons who checks, double-checks, and even sometimes triple-checks things during surgery to the extent that my partner and operating room staff often tease me about being so obsessive-compulsive.
Then it happened to me. I learned that we all make mistakes. It is easy. We are human. In fact, when I was forced to review the literature to produce a lecture on this topic, I discovered that the numbers of medical errors and wrong-site surgeries and the injuries they cause are unbelievable.
I became a convert, and in 2003 I was one of the surgeons and other health professionals and organizations standing with the Joint Commission on Accreditation of Healthcare Organizations strongly advocating and promoting the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The following account describes how I came to be there and what I learned along the way.
Anatomy of a Medical Mistake
In December 2000, a former partner of mine referred his best friend to me for treatment of an L3-4 disc herniation. The patient, an internist, was well known to me. Examination revealed a mild right foot-drop. A magnetic resonance image demonstrated a moderately large, very central herniated nucleus pulposus at L3-4, plus a very small extruded fragment on the right. The patient was scheduled for surgery a few days later, on a Monday.
The weekend before the surgery was particularly memorable for me, with several exciting events transpiring. When I came to the OR, I enjoyed telling everyone the weekend’s exciting details during the case. In addition, to accommodate the patient, I had elected to perform the surgery in the hospital where he practices, an excellent institution where I rarely perform elective surgery, although I do assist my colleagues in covering this facility. At my usual hospital, the rooms are rectangular and the operating table is always set up parallel to the long axis of the room in a grid-like fashion, whereas in this hospital, the operating table is frequently on a diagonal.
My usual routine is to scrub my hands, enter the room, check the X-rays and magnetic resonance images, then go to the side of the patient on which I intend to operate and finish prepping the skin with the antiseptic. At this hospital, the doctors are not permitted to prep the skin, so I had to enter, mark the site and help drape from the most accessible side of the patient. Aside from having a minimal acquaintance with the anesthesiologist, I knew no one else in the room, and as the case proceeded, I realized they also were inexperienced regarding my particular techniques.
I started the case standing on the patient’s left side because, as I entered the room with the table somewhat askew, I stood there to help drape. I took an X-ray to confirm my level, L3-4, as I exposed the lamina. I then proceeded with the laminotomy. I was easily able to identify a large central disc herniation, but no free fragment. A second X-ray was taken to confirm the level, and then I extended the small laminotomy cranially and caudally looking for the free fragment. A third X-ray confirmed that I was at the L3-4 level as intended. Eventually I incised into the large herniated disc and performed a discectomy. The small extruded fragment was not located, but I had long since learned that sometimes findings are not exactly as expected. I did detect and remove a large herniation, decompressing the cal sac and nerve roots.
Exiting the OR, I discussed the case with my former partner, the referring physician, including my concern regarding not finding the extruded fragment. When dictating the operative report, as soon as I stated the preoperative diagnosis of “large central disc herniation with small right extruded fragment,” I realized that I had been on the patient’s left side. When I explained my concerns to the OR technicians, they reassured me that I must have been in the correct place because I had uncovered and removed a large disc herniation and had checked and rechecked the X-rays. I debated the pros and cons of returning to surgery, with the thought that the significant decompression and excision of the large central disc probably would accomplish the desired goal of alleviating his radiculopathy. However, compelled by my conscience to return to the OR, eventually I convinced everyone that we needed to return to explore the patient’s right side. I discussed the situation with the patient’s wife as well as with the awakening patient himself; this was incredibly uncomfortable.
Back in the OR, I explored the right side at L3-4 through the same incision and located and removed the extruded fragment. My former partner called me a few hours later to advise me that the patient’s foot-drop had already significantly improved and he was doing great. The next morning the patient had no residual foot-drop, was comfortable, and was discharged. Two weeks after the operation he covered call for his colleagues during the holidays and was playing tennis within a few months. He greeted me as a friend whenever I saw him in the hospital, but I always felt too embarrassed to talk with him, other than simply to say hello.
Despite those facts, the patient did file a malpractice suit and the case was referred to the state board of medicine, as is appropriate for such cases. Those issues were a concern, but my greatest concern was simply the fact that I could make such a mistake. I was devastated. I started searching for answers to how this mistake could happen and how similar incidents can be prevented from ever occurring. Literature reviews revealed that many other instances of surgical errors have the same or very similar factors contributing to the errors. In almost all cases, there is a “systems breakdown” in which everyone participating in the case holds some responsibility.
Several factors contributed to my error. First, the case was not performed at my usual hospital. Second, the room setup was unfamiliar to me. Third, the OR staff was unfamiliar to me. Fourth, I was not able to prep the skin myself, which disrupted my usual routine. Fifth, I was distracted by the exciting events of the preceding weekend. Lastly, I knew something was wrong and felt I was in the wrong place but could not recognize that I had exposed the unintended side — what I call “oblivious to the obvious.” Later, recognizing these factors made me even more distressed at how easily such errors happen, and searching the literature and recognizing the frequency of these errors was an absolute eye-opener. Despite the fact that my patient made a rapid and excellent recovery, I still have nightmares about this case.
Toward a New Ideology and Culture
I decided that we must develop a new ideology and culture to recognize how such errors occur and to prevent them from happening again. This was further reinforced by listening, in horror, to some of the disastrous cases of wrong-site and even wrong-patient surgery presented at the board of medicine meeting I attended.
My recommendations, as presented at two national JCAHO conferences, are the following:
- We must do a better job of communicating between members of the OR team, and should involve the patients.
- The surgeon is no longer autonomous.
- We must emphasize teamwork and “systems” to succeed safely.
- There must be protocols and checklists.
- The surgeon must participate in development of new ideas to promote teamwork and safety.
- The OR staff is there to protect the patient.
- Our culture must change, and the goal and expectation must be perfection.
The protocols and checklists should include:
- Cases stating site and side should be posted in the OR and listed on the OR schedule.
- Consent forms should identify site and side specifics.
- The surgeon should visit the patient immediately before the surgery to reconfirm site and side and note it in the chart.
- When possible, the surgeon should mark the site and side (in the surgical field).
- OR staff should reconfirm the intended procedure and site and side immediately before surgery.
- Appropriate studies — X-rays, scans and data — must be available in the OR, plus confirmed by the OR staff to represent the appropriate patient.
Everyone in the OR is a part of a team. The individual team members are important, responsible parties who must communicate and interrelate in the OR in the interest of the patient. This must be a “systems approach.” We must focus on quality and accountability. Safety represents quality, and freedom from errors equates with good results.
Humans are fallible, but mistakes are preventable. We must devote more time and resources to developing teams of varying expertise within the operating room environment to work together toward the common goal of error-free surgery. Surgical errors are devastating for the surgeon just as they are for the patient and must be prevented.
Arnold A. Zeal, MD, FACS, FAHA, is chief of neurosurgery at Baptist Health System in Jacksonville, Fla.
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