W.A. 5.1
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Uploaded by combatvet1975
Wrong Site Surgery
rev. 12/2/2023
Written Assignment 5
HC Quality/Outcomes (HCM-4040-OL009)
12/2/2023
Safety Concerns
Wrong Site Surgery
rev. 12/2/2023
During his initial visit, the 49-year-old, we will call John Doe, went in for a colonoscopy
to be performed by a surgeon who identified a large tumor.
The pathology report indicated the
tumor could be suspicious for carcinoma.
The surgery was performed in a different location and
the surgeon tattooed the site.
Two weeks later, the same surgeon performed a partial colectomy
of the area in which he tattooed during the previous surgery.
After the surgery, the surgeon
reviewed the colonoscopy and pathology reports and found he had removed the wrong portion of
John’s colon.
The surgeon spoke with John’s family and scheduled another surgery for two days
later.
John should have spoken up following the first procedure regarding the tattooed area to
verify with the surgeon it was in the correct location.
Upon going to the ED, John should have
informed the ED staff of his recent surgery for the tumor removal.
This may have helped point
staff in another direction that could have prevented John from needing to make several trips to
the ED with the same symptoms, and possibly prevented another surgery.
Management should have been questioning the surgeon as to why they performed the
second surgery in the incorrect location.
A red flag should have also been raised when John
made three separate trips to the ED within a course of a month, having the same complaints of
fever, dyspnea, weakness, and cough with his antibiotic treatments.
Does reliability help?
According to the National Institute for Children’s Health Quality, reliability measures
how consistent the quality and safety of health care systems or processes perform over a required
period of time.
(NICHQ, 2020).
Was this wrong surgery site due to a lack of reliability?
Maybe.
It may have been due to a lack of communication in pre-op, or in the operating room.
Either of
these could have led to the disaster that had occurred.
There is also the possibility that the team
Wrong Site Surgery
rev. 12/2/2023
working with the surgeon had not all worked together prior to this surgery, resulting in a poor
outcome.
If a surgical team is going to have a known change to their personnel, management
needs to put in a concerted effort to find a replacement prior to the team member leaving.
Doing
so would mean the new employee can train side-by-side with the person they are replacing.
This
will give the new team member a better understanding of how the team works together prior to,
and during surgery.
The military is a great example.
When a unit deploys, they arrive in
Country a few weeks prior.
This allows the unit that is currently there to train their replacements
on how everything operates.
In turn, the transition is nearly flawless and makes it easier for the
new unit to understand exactly what their mission will be during their deployment.
Having a
reliable team ready for the surgery could have prevented the patient from having all the post-
surgery issues he had.
Safeguard
What safeguard/s could have helped prevent this from happening?
First, have a surgical
team prepared.
If a team has been working together for a long period of time, they know what to
expect and how to work together.
They are like a well-oiled machine.
If the team has not been
together very long, they may not communicate well, which in turn can lead to issues.
Also, if the
team is new or newer, consider having a checklist for pre-op, OR, and post-op.
This will help
prevent missing any critical steps before, during, and after the surgery.
The most important thing
a surgical team can do to prevent issues from occurring is to communicate.
When the team
communicates, it helps prevent errors.
Whereas a team, no matter how long they have been
working together, that does not communicate is more likely to experience issues than a newly
formed team that communicates throughout the entire procedure.
References
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Wrong Site Surgery
rev. 12/2/2023
An introduction to measuring reliability
. NICHQ. (2020, July 10).
https://nichq.org/insight/introduction-measuring-reliability#:~:text=Reliability
%20measures%20how%20consistent%20the,example%2C%20is%20considered%20very
%20reliable.
Ellsworth, W. A., IV, & Iverson, R. E. (2006). Patient Safety in the Operating Room.
Seminars in
Plastic Surgery
,
20
(4), 214–218. https://doi.org/10.1055/s-2006-951578
Whitworth , H. (2023, February).
Wrong site surgery
. MagMutual.
https://www.magmutual.com/learning/article/wrong-site-surgery/