Spotlight

Two Wrongs Don't Make a Right (Kidney)

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• This presentation is based on the March 2015AHRQ WebM&M Spotlight Case– See the full article at http://webmm.ahrq.gov – CME credit is available

• Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia– Editor, AHRQ WebM&M: Robert Wachter, MD– Spotlight Editor: Bradley A. Sharpe, MD– Managing Editor: Erin Hartman, MS

Source and Credits

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Objectives

At the conclusion of this educational activity,

participants should be able to:

• Review current definition of wrong-site surgery• Describe the incidence of wrong-site surgery,

and the impact the Universal Protocol has had on preventing wrong-site surgery

• Relate the key contributing factors to wrong-site surgery

• Discuss the current best practices to prevent wrong-site surgery

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Case: Two Wrongs Don't Make a Right

A 53-year-old man presented to Hospital A with abdominal pain and hematuria. Computed tomography (CT) imaging revealed a suspected renal cell carcinoma in the right kidney. He was transferred to Hospital B for surgical management.

All of the medical records from Hospital A documented a left-sided tumor—the wrong side. The CT scan from Hospital A was not available at the time of transfer and repeat imaging was not obtained by providers at Hospital B.

At the time of surgery, the surgeon was asked if the absence of an available image should preclude progressing with the surgery. He decided to proceed and, based on the available information, removed the left kidney.

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Case: Two Wrongs Don't Make a Right (2)

The day following the surgery, the pathologist contacted the surgeon to report no evidence of cancer. The surgeon then reviewed the initial CT scan and realized his mistake. The patient underwent a second surgical procedure to remove the right kidney (which was found to have renal cell carcinoma). Having lost both kidneys, the patient was then dependent on dialysis, and because of the cancer, he was not a candidate for kidney transplant.

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Background: Wrong-Site Surgery

• The Joint Commission defines wrong-site surgery as – Any surgery performed on the wrong site– Any procedure performed on the wrong patient– Performance of the wrong procedure

• Wrong-site surgery is a sentinel event—an unexpected occurrence involving death or serious physical or psychological injuries, or risk thereof

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Types of Wrong-Site Surgery

• Multiple subclassifications of wrong-site surgery:– Wrong level or part surgery (e.g., lumbar

discectomy on the incorrect level)– Wrong-patient surgery– Wrong-side surgery– Wrong-level exposure

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Contributing Factors & Root Causes

• Most wrong-site surgeries have multiple contributing factors and root causes

• For wrong-site surgery events reported to The Joint Commission from 2004 to 2014, the top 3 root cause categories were:– Leadership– Communication– Human Factors

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Contributing Factors & Root Causes (2)

• In a recent systematic review, contributing factors to wrong-site surgery included:– Incorrect patient positioning or preparation of the

operative site– Incorrect or lack of consent– Failure to use site markings– Surgeon fatigue– Multiple surgeons– Unusual time pressures– Overall poor communication

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The Universal Protocol

• The "Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery" became effective in July 2004

• The protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities

• The Universal Protocol was designed to engage institutions in implementing a standardized approach to surgeries and procedures

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The Universal Protocol (2)

• The protocol includes many recommended steps but there are three principal elements1) Preprocedure verification

2) Site marking

3) Time out prior to incision

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Frequency of Wrong-Site Surgery

• Between 1995 and 2005, wrong-site surgery was the second most frequently reported sentinel event

• Despite implementing the Universal Protocol in 2004, wrong-site surgery remains the second most frequently reported event in 2014– Wrong-site surgery accounted for 12.8% of

sentinel events from 2004 to 2014

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Frequency of Wrong-Site Surgery (2)

• Yet, these events are self-reported so likely represent a small proportion of actual events

• Calculating the true frequency of wrong-site surgery has been difficult– Estimated rate of wrong-site surgery varies

widely, ranging from 0.09 to 4.5 per 10,000 cases performed

• Most patient safety experts would maintain that even one wrong-site surgery is too many

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This Case

• There appear to be four errors that resulted in this sentinel event:– A documentation error on the medical records

from Hospital A– Only the records but not the actual imaging

accompanied the patient at the time of transfer– The patient went to the operating room without

preoperative imaging– The labeled radiology images were not present in

the operating room at the time of surgery

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This Case (2)

• The error in this case could have been prevented even after the first 3 errors

• The Universal Protocol suggests having the labeled radiology present in the operating room at the time of the surgery

• The surgeon proceeded without the imaging, leading to the adverse event

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Preventing Wrong-Site Surgery

• Despite widespread implementation of the protocol, no evidence exists to substantiate the effectiveness of the Universal Protocol in preventing wrong-site surgery

• Yet, there is no evidence to support other interventions

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Preventing Wrong-Site Surgery (2)

• The Joint Commission does support modification of the protocol by specific surgical specialties

• For example, the North American Spine Society has recommended that, in addition to the Universal Protocol, intraoperative imaging following exposure and marking a fixed anatomic structure should be used to determine the correct level of spine surgery

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Other Interventions

• Other interventions may have prevented error in this case

• For example, there could be a hospital policy requiring imaging to be present in the operating room

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Summary

• The Universal Protocol can be a useful tool in preventing wrong-site surgery, but the implementation can be variable

• Health care administrators, providers, and surgeons should ensure the protocol is implemented as intended

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Take-Home Points

• Wrong-site surgery should be preventable• Estimated rate of wrong-site surgery varies widely

ranging from 0.09 to 4.5 per 10,000 cases performed• Wrong-site surgery remains the second most frequent

sentinel event reported to The Joint Commission• The Universal Protocol has been in effect since July

2004 for all accredited organizations providing surgical care. The protocol's effectiveness is only as good as the policies guiding its use and the personnel charged with applying those policies.