Surgical Never Event - Surgery on the Wrong Knee

Wrong-site surgery incidents are usually due to multiple processes that combine to cause the event, as opposed to one specific error.

As with the other never events discussed in the linked case studies, a range of risk reduction strategies are necessary to prevent wrong-site surgery. Site marking has reduced wrong-site surgery, but has not eradicated it. The Joint Commission recommends (and studies indicate that) active communication and shared responsibility among surgical team members — including time outs, team briefings, and checklists to verify correct patient, site, and procedure — can further reduce the incidence of wrong-site surgery.¹ In the following case, the site was marked correctly, but other protocols were overlooked. Consider what the surgical team members could have done to prevent the error.

Allegation

The patient alleged medical negligence and battery due to lack of consent for surgery on her right knee.

Case File

A patient presented for arthroscopic repair of a meniscus tear of the left knee. The surgeon marked the left knee and obtained the patient’s consent for the left knee procedure. During induction, the patient’s right leg fell off of the operating table. The circulating nurse placed the right leg back on the table, and started prepping the right knee. The circulating nurse performed an operative time out. As part of the time out, she stated right-knee arthroscopy. Everyone on the operative team stated “agree.” The surgeon started the surgery before the time out was concluded. No one noticed the surgeon was operating on the wrong knee. When the drapes were removed following surgery, the mark was clear on the patient’s left knee. The patient claimed medical negligence and battery, as she had never consented to surgery on her right knee.

Discussion

If the patient’s leg had not fallen from the operating table, this case probably would have gone as planned. Most correct-site surgery protocols include redundancies to catch an incorrectly prepped site. Communication-related protocols in this case were not followed, including:

• The surgeon did not perform the time out and started the surgery prior to its conclusion.
  • The surgeon’s disregard for the process was a poor example for the other members of the team and also unnecessarily increased the risk of patient injury, as well as liability for himself and the rest of the team.
• The location of the surgery was not read out from the consent form.
  • Reading out from the consent form is another safety measure that can clarify site location mistakes that may occur on the path to the first incision. If the correct site had been called out, someone might have noticed before it was too late.
• The surgeon did not check for his mark prior to surgery.
  • Checking for the mark just prior to incision was the surgeon’s last opportunity to ensure he was at the correct location.

Following any one of the protocols the team did not follow might have alerted them to the incorrect site.

Resources

The Joint Commission. “The Universal Protocol.”

American College of Surgeons (ACS). “Revised Statement on Safe Surgery Checklists, and Ensuring Correct Patient, Correct Site, and Correct Procedure Surgery.” 2016.

Risk Reduction Strategies

Consider the following strategies:^1,2,3,4

Surgeon

• Actively lead the pre-surgical briefing or time out.
• Do not start surgery until the briefing or time out is complete.
• Check for your mark before you make the first incision.
• When working through a correct-site protocol, check the prepped site against the site identified in the informed consent document.
  
  

Surgical Team

• Be an active participant in correct-site protocols.
• Do not confirm that the site is correct unless you look at the prepped site (the site marking should be visible after draping) and listen to the surgical site being announced.
• Speak up if a colleague is not following a patient safety protocol.
• Do not assume the site is correct based solely on which site has been prepped.
• Use a standardized checklist that includes correct-site protocols.
  
  

Administrators

• In addition to an operating room safe surgery checklist that includes patient, procedure, and site confirmations, use a master checklist that covers the perioperative surgical pathway, such as the Association of periOperative Registered Nurses (AORN) “Comprehensive Surgical Checklist,” which provides multiple opportunities to affirm correct patient, surgery, and site.
• Share wrong-site and near miss examples during department meetings or training sessions to raise awareness about inconsistent safety practices and to show how protocols can prevent errors.
  
  

1. Arvid Steinar Haugen, et al. “A Survey of Surgical Team Members’ Perceptions of Near Misses and Attitudes Towards Time Out Protocols. BMC Surgery. 2013;13:46. DOI: 10.1186/1471-2482-13-46

2. Susanne Hempel, et al. “Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review.” United States Department of Veterans Affairs. September 2013.

3. The Joint Commission. “The Universal Protocol.”

4. American College of Surgeons Committee on Perioperative Care. “Revised Statement on Safe Surgery Checklists, and Ensuring Correct Patient, Correct Site, and Correct Procedure Surgery.” Bulletin of the American College of Surgeons. October 1, 2016.