Wrong-Site Surgery

Wrong-Site Surgery

Read the following case study scenario:

Wrong-Site Surgery

Mr. Adams arrives in the preoperative area in Lincoln General Hospital for thyroid surgery. He states to the pre-op nurse that he needs the right side of his thyroid gland removed. His statement confirmed by the posting sheet, which indicated the patient is schedule for right thyroid lobectomy. The operating room nurse verifies the posting sheet with the patient statement, as well as with the anesthesiologist. The surgeon, Dr. Ruiz, confirms the right lobe is to be removed as stated in his office notes. The patient is taken to the operating room and he undergoes a right thyroid lobectomy.

The surgeon finds multiple nodules in the specimen but is concerned they do not appear to be as prominent as the nodules he expected. While in the recovery room Dr. Ruiz reviews the preoperative ultrasound and realizes that the majority of the disease was in the left lobe of the thyroid. Dr. Ruiz discusses the situation with the patient’s wife and returns the patient to the operating room and removed the left lobe of the thyroid.

What are the facts of this situation?

Ruiz was faced with two choices. He could have said nothing and let Mr. Adams go home. When the surgeon saw Mr. Adams in his office for follow up, he could have told him he needed more surgery at that time. Or he could have done what he chose to do (pursue returning the patient to surgery and doing the appropriate operation). Discuss the pros and cons of both options.

Five people (the patient, pre-op nurse, OR nurse, anesthesiologist, and the surgeon) all thought the surgery was supposed to be done on the right lobe of the thyroid. What went wrong? Could this have been avoided? If so, how?

If, in fact, Dr. Ruiz performed a wrong-sided procedure, what would be the next steps in reviewing this problem? What consequences might there be for Dr. Ruiz and the hospital staff?

The heart of quality improvement and patient safety is being honest and fearless enough to look at errors in a health care organization. What kind of effective systemic approached might be used to avoid these types of scenarios? Provide your reflections and personal opinions as well as your recommendations and rationale for your responses.