Wrong Site Procedures
Wrong site surgeries and procedures still plague health care organizations across the country. Although relatively rare compared with retained foreign objects, wrong site procedures are still a problem. Not limited to just the wrong limb or wrong side organs, these mistakes can encompass removing the wrong lesion on a site with multiple lesions.
The Joint Commission defines wrong site surgery/procedure as an "invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure." There are numerous studies and performance improvement initiatives that attempt to eliminate such surgical errors, but uncontrollable human factors make it difficult to completely eradicate the problem. Here at Stanford, we are vigilant to this fact and work toward a goal of zero wrong site surgeries. However, we have had such events in the past, which fortunately have not led to permanent patient harm.
One such event involved an elderly man who presented to the Dermatology Clinic for a suspicious lesion on his head. The patient had a history of multiple prior lesion removal for basal cell adenocarcinoma and squamous cell carcinoma located near the newly identified lesion. The patient care team followed standard processes in obtaining the biopsy and photographing the lesion with appropriate documentation. The patient presented to the surgery clinic as scheduled and underwent a Mohs procedure three weeks after his biopsy. When the tissue sample came back from pathology, it showed no disease. Upon further investigation by the physicians, it was believed that the wrong lesion was excised. If all of the policies and procedures were followed, what happened?
A Root Cause Analysis (RCA) was performed with all of the involved staff and physicians. The RCA showed a number of failures. The photograph taken by a temporary employee was suboptimal due to lack of training and experience in photography. Three weeks elapsed between the day of the biopsy and surgery, allowing the site to heal. The patient ran into a tree branch two days prior to surgery, which caused a scab to form in the area of the lesion. The physician performing the biopsy was out of the office on the date of surgery and unable to confirm the exact site in person. A different physician present for the biopsy confirmed the site. And lastly, the patient himself looked at the site and believed it to be the correct one.
When events like this occur, it is very rare that one single thing led to the error. Instead a cascade of events attributed to the outcome. To eliminate such events from recurring, several new system processes were put into place. There is now additional training provided to staff on how to photograph the site; and only trained staff, not temporary staff, may perform the task. The clinic purchased new photography equipment to ensure optimal quality. Photographs are to be automatically uploaded to the electronic medical record to minimize distortion. Finally, if there is any question about the site, the physician will not proceed with the procedure.
While this improvement plan sounds relatively simple, it takes continual vigilance and dedication by the staff and physician to sustain the process. We have still encountered near misses. But because of the processes put into place following this event, similar errors have been prevented. Lesson learned.