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Wrongfooted

how failure of process and inadequate WHO checklist participation led to the wrong foot being operated on.

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  1. I would like to thank my medical director for the permission to talk about this openly, and widen the scope of learning beyond our hospital to a much bigger arena.

    This happened on a routine orthopaedic operating list not that long ago:

    The orthopaedic surgeon involved had a busy list booked with 6 patients on it. He didn't have a registrar with him as he normally would have which made him late for the start of the list. 

    The patient had a problem with both feet and was keen to get both operated on at the same time. The surgeon, however explained that it would be safer to get one foot done, then come back for the other once that had healed. The patient agreed, and between them they agreed to do the right foot. The leg was marked and consent form done.

    The scrub nurse did mostly urology and was somewhat unfamiliar with the equipment needed for this operation. Some of it was missing and extra equipment had to be fetched from another theatre suite. In addition, equipment for the last patient on the list had to come from another hospital. This added an element of stress to an otherwise straightforward list.

    The anaesthetist saw the patient pre-op. She didn't check which leg was to be done, as this didn't affect the anaesthetic.

    The anaesthetic nurse had checked the patient in on the ward (just across the corridor) and completed the 'sign in' part of the WHO checklist at the same time. He noticed that the patient hadn't been given a TED stocking for the leg not being operated on, so asked the nurse on the ward to provide one.  The ward nurse gave the patient the stocking to put on but left before she had done so.

    The patient put the stocking on the right leg.

    The patient was then brought through to the anaesthetic room, the checks had already been done on the ward, the anaesthetist and the anaesthetic nurse proceeded to anaesthetise the patient and brought her through into theatre.

    The surgeon had not communicated with the theatre staff the day before saying what he needed, so the theatre nurses were late preparing the equipment, and were still trying to get equipment after the patient had been anaesthetised. The nurse in charge was telephoned repeatedly about refrigeration arrangements for implants coming from another theatre suite. The second scrub nurse was sent upstairs to collect missing equipment when the patient was brought in.

    The WHO checklist was read out by the anaesthetic nurse. The surgeon was listening, but was scrubbing up in a side room. The left (wrong) leg was exposed as the stocking was on the right leg. The nurse in charge was on the phone, the second scrub nurse was upstairs getting equipment. The anaesthetist was busy getting the patient settled on the ventilator. The scrub nurse - unfamiliar with the kit for this operation - was concentrating on laying out the equipment. She assumed the anaesthetic nurse had checked which leg was on the consent form.

    The surgeon came through and operated on the wrong leg.

    At the end of the operation he requested an X ray, and the radiographer pointed out that the request had been made for the right leg, not the left.

    The surgeon went pale as he realised his mistake. All the theatre staff became extremely upset and frightened. The surgeon finished the operation and tried to calm the theatre staff. He then phoned his clinical director - who was busy and asked to phone him back. Then he phoned the legal department who advised him to complete the operation on the other side.

    He did as advised, spoke to the patient afterwards (who incidentally was delighted) and he reported the incident according through the trust Datix system.

    The patient made an uneventful recovery. She was followed up and counselled about what happened. She was informed that an investigation would take place, we would distribute learning points and change our procedures.

    The surgeon was initially removed from clinical duties.  The investigation into the incident was completed, everyone involved was interviewed, their responses analysed, and a serious incident report drafted. In the meanwhile the WHO checklist policy was amended, and clear lines of responsibility drawn: the Sign-in is the responsibility of the most senior anaesthetist, the time-out and sign-out the responsibility of the most senior surgeon.

    This incident changed the performance of the WHO checklist overnight.  I noticed this immediately in theatres, particularly among the orthopaedic surgeons.  Was this fear of repercussions if this happened to them or a realisation that the team check only works well if everyone participates in it? In any case, within days the safety culture in theatres had transformed.  There was a lot of discussion about it in coffee rooms, in theatres and by email, and especially that a single task of putting a stocking on could derail the whole check-in process.

    I feel I need to emphasise what a devastating effect an incident like this has on the staff involved. As I have already hinted above, the nursing staff were inconsolable.  The anaesthetist involved slept extremely badly for weeks afterwards, both out of worry, and guilt.  The staff involved were good conscientious people, who only wanted to do their best for all the patients on their operating list.

    After the event, the anaesthetist involved organised an audit of compliance with the WHO checklist procedures and presented this at the local audit meeting.  In addition she re-staged the check-in procedures using staff playing the roles of patient, anaesthetist and anaesthetic nurse.  She filmed it and showed it at the meeting.  Everyone present was profoundly affected by it, and this was one of the most powerful learning opportunities after the case. 

    On Monday 14th October I attended the final meeting with the medical director, HR consultant and the anaesthetist involved.  I felt strongly that this incident was a fantastic opportunity to demonstrate how safety works, and if we limit its distribution to within the hospital walls we are doing patients an enormous disservice.  The fact that the mistakes were in themselves innocuous, the situation was one recognised by most health professionals working in busy hospitals, and that all of the contributing factors were due to human error makes it a brilliant learning case.  In addition, with no harm done to the patient it somewhat negates a lot of the emotional "knee jerk" reactions, and allows us to concentrate on how teamwork and concentration can improve patient care.

    I remain indebted to our medical director for not only permitting this post, but positively encouraging it.  It's a brave step, but I truly believe an extremely positive one for patient safety.



    Below I have added some of the reactions from twitter. For some reason, the facebook links are harder to put in here, reinforcing for me the feeling that facebook is for friends and twitter is for public discussion. The "Medical Registrar" on facebook shared it and there are some interesting comments on there, some helpful, some displaying a lack of appreciation of how mistakes occur.

    Update on 13th December:
    I have been amazed by how much attention this story has received.  This culminated with the story being mentioned at the GMC conference yesterday as a part of a discussion on how social media can be used for learning in medicine.  

    I spent about two hours talking to the patient involved yesterday.  She is absolutely thrilled that the lessons from her experience have been shared so widely.  She wants to emphasise how happy she was with her surgeon's care for her, and asking how she felt on the day, I feel the report above is pretty correct, particularly regarding the rushed atmosphere with everyone trying their best despite last minute changes in staffing and in list order. I am indebted to her and her willingness to be part of this learning experience.   
  2. The day after Dermot reported their own case. So similar, the causes pretty much the same. He also talks about what happened after he sent their investigations to NHS England, and their apparent failure to share it. Please read it.
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