In this section, we share clinical cases of adverse events that occur more than they should at major surgical departments and teaching hospitals around the globe. While the cases may sound familiar, they are not actual patients, but are conglomerations of scenarios that we have heard of and have been studied by local patient safety teams. The approach to these events was to understand, on a systemic basis, what went wrong and as Gawande mentions in his book “The Checklist Manifesto,” how to make things go right. These clinical cases represent an educational basis towards patient safety issues in surgical settings. Situational awareness, communication failures, and other non-technical skills are leading issues in these cases and are often the leading causes of errors occurring in surgery patients.
15.1 “I was rather sure that they were here!!!” The Case of the Missing Forceps
15.1.1 Case Analysis According to Risk Management Approach
Setting: A major teaching hospital. A 72-year-old male patient undergoing general surgery for right-sided colon cancer.
Procedure: Open right hemicolectomy under general anesthesia.
Team: Performing surgeon, assistant surgeon (trainee), scrub nurse, anesthetist, assistant nurse.
Procedure time: 3 hours without any delay.
A 72-year-old male patient was submitted to general surgery for a right-sided colon cancer. The surgeon performing the procedure clearly informed the patient that the procedure was a right colon resection by an open laparotomy approach. The patient was admitted to ward; prepared for surgery according to recent protocols applied in the hospital and surgery began at 9:45 a.m. The day of surgery was Thursday; no apparent organizational mishaps; the performing surgeon had 20 years of experience and the assistant surgeon (a trainee) has 4 years of experience. Both had performed a sufficient number of bowel surgeries to be comfortable. The scrub nurse has 15 years experience in abdominal surgery procedures and has been recently trained on laparoscopic procedures. The anesthetist is a 20-year veteran, experienced specialist and chief of the intensive care staff. The assistant nurse has 7 years of experience in the operating theater. No particular concerns are noted until at nearly 1 h from beginning the performing surgeon came across massive bleeding due to an incidental lesion of a mesenteric vein branching form an unusual site. This event caused some confusion amongst the team, and many sponges were used to pack the bleeding site and surgically ligate and repair the damaged vessel. The vessel damage also required an extension of bowel resection—due to involvement of the remaining bowel so as not to cause severe hypoxia to the remaining organ tract. This accident caused the surgical team to apparently “lose control” of the setting and situation, having been concentrated on avoiding massive bleeding and shock. The procedure resumed after 1 h and finished 1 h later. Much confusion was perceived in the theater and the anesthetist urged to finish as quickly as possible because patient had several critical low blood pressure episodes.
The performing surgeon left the operating theater and asked the assistant to suture and close the laparotomy incision. The assistant nurse was occupied with another patient and called another nurse to attend the sponge and instrument counting procedure. The assistant surgeon left the operating theater without confirming the sponge or instrument count. The patient was accompanied to the ward and discharged after 10 days from the hospital.
The patient returned for surgical and oncological follow-up and a first visit was scheduled 1 month from surgery. The surgeon visits the patient and asks him several questions regarding his health status after surgery. The patient states that no particular symptom or situation occurred after surgery except for recurrent episodes of lower right back pain responding to common analgesia medications. The patient was sent to ambulatory for blood sampling and then addressed on the same day for a plain X-ray of the abdomen. Blood test values were normal in range but the X-ray demonstrated a metal foreign body in the lower right abdominal quadrant which clearly represented a 12 cm surgical forceps.
This case was submitted to the clinical risk management and patient safety team of the hospital and a root cause analysis approach was proposed to investigate the unintentionally retained foreign object (URFO). The entire surgical staff was invited, the case was discussed, and an improvement plan was agreed upon. Since then, no member of the surgical team leaves the operating room without assuring sponge and instrument count is correct and all parties agree. A surgical safety checklist was implemented that explicitly tasks individual team members with certain steps based on their roles. For example, the surgeons re-inspect the surgical wound while the circulating nurse calls early for X-ray to rule out a retained object. Quality assurance controls performed every 6 months to assess compliance to safe surgery issues.
The importance of a clinical risk management and patient safety policy is a fundamental managerial aspect of safe health care and these principles must be embedded into all levels of leadership governing hospitals and health care institutions. Patient safety awareness must be a convincing issue to deal with when quality performance indicators are discussed and monitored to achieve best levels of safety and safe care. Teamwork, communication, and a shared sense of responsibility are useful practices to encourage a culture of safety in the surgical setting.
15.2 “I used to move my left arm before surgery” A Case of Patient Positioning on the Operating Table
15.2.1 Case Analysis According to Risk Management Approach
Setting: A regional hospital. 54–year-old female patient undergoing breast surgery
Procedure: Left external quadrantectomy for a suspected breast cancer and sentinel lymph node detection
Team: Performing surgeon, assistant surgeon, scrub nurse, anesthetist, assistant nurse
Procedure time: 3 hours without any delay
A 54-year-old female patient was admitted to a general surgery ward in a regional hospital. The patient presented with a suspected breast cancer nodule located in her left breast in the upper left quadrant. The surgery was posted for an upper left quadrantectomy and sentinel lymph node biopsy. She was placed on the operating table according to usual and routine position indications by the surgeon prior to surgery. Two assistant nurses positioned the patient and extended her left arm and positioned it according to surgeon’s directions. The operation was performed and lasted 3 h.
Upon awakening, the patient was unable to move her left arm and had sensation of paralysis. This symptom was investigated further and a partial temporary paralysis of the brachial plexus was revealed by electromyography examination. A root cause analysis revealed a series of mishaps and pitfalls that were discussed in a morbidity and mortality conference with all surgeons and operating room personal.
Improvement suggestions were to provide the operating room with diagrams and/or pictures or any other visual means of patient positions on the operating table in relationship to the specific surgical procedure. Each performing surgeon and anesthetist must control patient position before surgery and nurses must be trained on safe maneuvers. Specific risks based on the patient positioning should be understood by all team members to ensure appropriate prevention techniques are undertaken. Peripheral nerve injury is a common potentially preventable complication of poor patient positioning. Nerves can be injured by either of two mechanisms: stretch or compression. Common nerve injuries from patient positioning during surgery to consider are to the brachial plexus and its branches (commonly seen during breast surgery) or peroneal nerve injury during surgery performed in lithotomy position. Pressure injury is another common risk from ineffective postponing or padding and can be seen in numerous areas including the sacral region for supine cases or the face in prone cases.
15.3 “My clinic note said to remove the left lung nodule” A Case of Wrong Site Surgery
Setting: A major teaching hospital. 65-year-old male undergoing video-assisted thoracoscopic (VATS) wedge resection.
Procedure: Right Video-Assisted Thoracoscopic Surgery (VATS) Wedge Resection.
Team: Surgical Attending, Surgical Resident, Scrub Nurse, anesthetist, circulating nurse, pre-op nurse.
Procedure time: 1.5 h.
The patient is a 65-year-old male a history of pancreatic adenocarcinoma s/p pancreaticoduodenectomy in 2015 who presented to clinic with bilateral pulmonary nodules. Recent CT imaging demonstrated a 1 cm nodule on the right side in the lower lobe and a 7 mm nodule in the left lower lobe. Both nodules were peripherally located within the lower lobes. CT guided biopsy revealed a metastatic nodule on the right and benign disease of the left lower lobe nodule. He was referred to the thoracic surgery clinic for evaluation and surgical management for tissue diagnosis. The consulting surgeon planned for a VATS wedge resection of the right lower lung nodule and documented the existence of both nodules in his assessment and plan. He was posted on the surgery schedule for a right VATS lower lobe wedge resection. However, the plan on the most recent clinic note indicated that the patient would undergo a left lower lobe wedge resection.
On the day of surgery, the patient presented to the pre-op area and was consented by the surgical team for a left lower lobe wedge resection after the plan on the clinic note was reviewed. The patient was marked on the left side, which was confirmed by the nurse in the pre-op area. In the operating theater, during the “operative time out” the left side was again noted to be the correct side and all the parties in the operating theater agreed. The patient underwent a left VATS wedge resection. This nodule was sent to pathology as a frozen specimen and was noted to be benign. At this point, the surgeon broke scrub to review all the previous documentation, pathology notes and CT imaging. He realized that he had performed a wedge resection of the incorrect site—a “wrong site procedure.” The team proceeded with the VATS resection on the correct side, and the patient recovered uneventfully.
When discussed, numerous points of failure were noted and the team realized there were lessons to be learned. First, they all realized that the discrepancy between the posting (Right VATS) and the procedure they agreed to perform (Left VATS) should have raised suspicion and led to a more thorough double check. Second, they did not include the patient in the discussion. When asked in retrospect, he stated that he did not want to speak up since he just assumed “the doctors and nurses knew what they were doing.” Third, they agreed that the imaging should have been displayed (which would have shown two nodules) and then, the pathology should have been double checked to ensure the correct side was operated on. Other contributing factors included the fact that the team felt pressure to proceed quickly to get all the multiple cases for the day completed in a timely fashion.