A surgical disaster: Could this happen in radiology?: A case report

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Merry Lester
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1 A surgical disaster: Could this happen in radiology?: A case report The Cases Time Out: A WHO initiative for safer patient care By Dr D Catherine Mandel, Peter MacCallum Cancer Centre, Melbourne, Victoria The surgical disaster A patient was admitted to hospital for a left nephrectomy. The admission form was completed incorrectly by a junior resident: he wrote right nephrectomy. This incorrect information was transferred to the theatre list by another junior doctor. As the consent form stated left nephrectomy the patient had no reason to be concerned. The discrepancy between the theatre list and the consent form was not discussed, investigated or resolved, the surgeon being sure that a left nephrectomy was correct. The operative site was not marked prior to anaesthesia. The X-rays were misinterpreted (it seems likely that they were placed back to front on the light box). The patient s healthy left kidney was removed: the mistake was detected two hours after the operation when it was noted that the patient had not produced any urine. Five weeks later the patient died. The consultant surgeon and the surgical registrar were charged with manslaughter but later cleared as a direct causal link could not be proved. Is this just a problem for surgeons or could a similar mistake be made by a radiologist? Radiology Cases Case One A 55 year old man arrived at the radiology department of a large teaching hospital for a nuclear medicine study. The booking on the radiology information system was for a cardiac gated blood pool scan. The study was done and the images given to the nuclear medicine consultant for reporting. When she looked at the paperwork it became clear that the patient had been referred for a bone scan. He had a past history of prostate cancer and a new increase in prostate specific antigen. The man was quite anxious and there was little discussion of the procedure with the patient, other than to give him instructions, and no one asked him why he was there or what he thought he was having done. The patient had, in fact, been told that he was being referred for a bone scan, but at the practice it was only ever referred to as a scan or your scan. The patient was rebooked for the correct test the following week. Case Two Mr John Hamilton arrived at the reception desk of another radiology department for a bone scan: he had a past history of cancer and was being investigated for new symptoms. He was quite anxious. After waiting for about ten minutes he heard his name called by a radiographer. The patient was taken to the CT scanner and had a CT neck and chest performed. It was only after the CT scan had been done that the radiographer realised that he had scanned the wrong patient. Another Mr John Hamilton was also booked to attend the department on the same day Surgical Disaster Could this happen in Radiology?: A Case Report QUDI enews, June

2 for a CT scan. Unfortunately the request form for this patient did not have a date of birth or UR number on it despite this being against hospital policy. The first patient had his bone scan performed later that day and the second patient had his CT scan performed at the scheduled time. Case Three A patient arrives at a radiology practice with a hand written request for an X-ray of the left forearm. The clinical notes were ORIF and what was thought to be L forearm. In retrospect the writing was very difficult to read. The left forearm was X-rayed but no internal fixation could be identified. The patient spoke little English and had had several fractures following a motor vehicle accident so did not question the radiographer. After further investigation it became clear that the right forearm should have been X-rayed. The correct body part was then X-rayed. Analysis and a practical way to address the problem These incidents happened, not because someone set out to do the wrong test, but because critical information was assumed or not actively sought and confirmed before commencing the procedure. These sorts of problems occur every day in all areas of medicine. Most of the time no lasting harm occurs but occasionally someone dies because of a simple error. A safety checklist The World Health Organisation (WHO) has recognised that these failures to obtain critical information are a significant problem. In June 2008 the WHO launched its second global patient safety challenge: safe surgery saves lives (SSSL). As part of this programme a surgical safety checklist was developed. An analysis of almost 8000 patients in eight cities was published in the New England Journal of Medicine in January 2009: e=hwcit In this study the death rate fell from 1.5% to 0.7% and the recorded complication rate from 11% to 7%. All this by implementing a simple 19 point checklist. There are many resources available on the WHO website: These include an implementation manual and the WHO checklist: The checklist (below) has three components; sign in, time out and sign out. It is read out to the team with the verbal responses recorded on the form, then filed in the patient history or scanned into the RIS. Sign in involves the patient confirming his or her identity, the site and nature of the procedure and that consent has been given for that procedure. In addition anaesthesia safety checks, known allergies and other specific risks are checked at this stage. Time out, the second stage, involves ensuring that the team members have been introduced to each other by name and role (this is particularly important when there are new or casual staff members or two teams working together). The staff involved in the procedure verbally confirm the details of the patient, the site to be treated and the procedure. At this stage the operator (a surgeon or a radiologist) reviews any critical steps, potential complications or other isues that the rest of the team need to know about. Nursing staff confirm that equipment is properly sterilised and that all the equipment that may be needed is available. Any anaesthetic issues and needs are also reviewed and addressed at this stage. Antibiotic prophylaxis is confirmed as given within the last 60 minutes or confirmed as not necessary. Confirmation of essential imaging being available and displayed is noted. Sign out occurs at the end of the procedure. This involves ensuring that the procedure is correctly recorded, instrument counts are correct, any specimens are labelled and equipment problems noted so arrangements can be made to fix them. Finally the operator, anaesthetist and nurse review key matters for the patient s post-procedure care and recovery, and any other matters important for the patient s care. Surgical Disaster Could this happen in Radiology?: A Case Report QUDI enews, June

3 Who is using the WHO checklist? Many patient care organisations are endorsing and implementing the WHO surgical safety checklist. It might be more appropriately called a patient safety checklist as it is of great value in many areas on medicine, not just surgery. Different organisations have adapted the checklist to suit local conditions. The Australian Commission on Safety and Quality in Healthcare has produced its own version of time out. The document can be found at: 1BCA2571D30023FBB5/$File/ensureposter.pdf More information can be found at: The Royal Australasian College of Surgeons supports the use of the WHO safety checklist. Their version can be found at: ons/who_surgical_safety_checklist.pdf The UK s National Patient Safety Agency is co-ordinating a drive to introduce this initiative across the UK. It is being done in conjunction with many of the Royal Colleges and other professional organisations. There is a wealth of information at: The organisation most relevant to us is the Royal College of Radiologists. They have confirmed that the safety check applies to radiology and have issued guidelines for implementation of the safe surgery checklist: Surgery_Requirement_March_2009.pdf In the UK it is expected that the checks will be undertaken for all patients undergoing diagnostic or interventional procedures. Whilst at first it might seem to be overkill to do this for all diagnostic tests, it is clear that things can go wrong with even the simplest of tests such as an X-ray of a limb. Completing the relevant parts of the checklist would have detected the problem before things went wrong. The RCR has devised a practical sample checklist that would be easy and quick to use. Conclusion Small errors can have disastrous outcomes. A simple checklist, completed correctly can reduce error, improve patient care and save radiologists and other healthcare workers from the stress of avoidable patient harm. Surgical Disaster Could this happen in Radiology?: A Case Report QUDI enews, June

4 The WHO surgical safety checklist Surgical Disaster Could this happen in Radiology?: A Case Report QUDI enews, June

5 COPYRIGHT NOTICE: This report is protected by copyright. No part of this publication may be reproduced or copied in any form or by any means without the written permission of the Royal Australian and New Zealand College of Radiologists. For written permission to use the information contained in this report, please contact the RANZCR: DISCLAIMER: Responsibility for the content of this report resides solely with the authors. The views and opinions expressed in this report, including key recommendations and findings are strictly the views and opinions of the authors and not officially sanctioned by the Royal Australian and New Zealand College of Radiologists. NOTE: The RaER project was funded by the Australian Commonwealth Department of Health and Ageing under the Quality Use of Diagnostic Imaging Program. Surgical Disaster Could this happen in Radiology?: A Case Report QUDI enews, June

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