This week, we will continue our discussion of an incident where the wrong surgery was performed on a patient. Last week, we looked at the timeline of events and a process map of the universal protocol developed to reduce the incidence of surgical errors. This week, we’ll perform a root cause analysis of the issue.
The specific steps identified that didn’t go well, or weren’t performed, from the process map now become causes on our Cause Map. Instead of the causes or errors being grouped chronologically or by type (as they are on a fishbone diagram), the causes are grouped by their contribution to the incident. The Cause Map reads from left to right by asking “Why” questions, beginning with the impacts to the goals.
For example, the patient safety goal was impacted because a patient received the wrong surgery. Why? Because the physician performed the wrong type of surgery. Why? Because the surgical site was not clearly marked. Why? It was marked on the correct arm, though not the correct site (the wrong surgery was performed on the correct hand) and the mark was washed off during patient preparations. These are both issues identified in the process map that did not follow the universal protocol for surgical preparations. Both of these issues contributed to the wrong surgery. In addition, the surgeon was thinking about carpal tunnel surgery, since most of his day, especially just prior to the surgery, had been spent on carpal tunnel surgery, either performing it, or doing pre- or post-surgery briefs with other patients.
Neither the patient nor the operating room staff stopped the surgeon from performing the incorrect surgery. The patient spoke only Spanish, which may have contributed to her not speaking up. The operating room staff did not include the nurse that had done the patient assessment, due to a last-minute operating room and staff switch due to other delays. There was no time-out prior to the procedure, which may have alerted the staff about the wrong procedure, or may have helped the surgeon switch from thinking about carpal tunnel surgery.
Once the analysis is complete, possible solutions are identified on the Cause Map. Many of the solutions in this case are to ensure that the universal protocol procedures are being followed. Had they been followed in this case, the risk of performing the wrong surgery would have been reduced. Many facilities are already using the universal protocol; however, this case study shouldn’t be ignored by them. The operating surgeon made this case public and added the following comment: “I hope that none of you ever have to go through what my patient and I went through. I no longer see these protocols as a burden. That is the lesson.”
This surgeon has learned his lesson and will likely be more diligent about following these protocols in the future. However, there’s no need to wait until you, or your staff members, have their own incidents to learn from. Use this case study to emphasize the needs for these protocols, in hopes that your facility can reduce its own risk.
(Details of this incident were recently published in the New England Journal of Medicine.)