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June 1996
Volume 60 |
Number 6
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Anesthesia and
Surgery:
Not Always a One-Sided Affair |
Stephen R. Strelec, M.D.
Committee on Professional Liability
Wrong-sided surgery has found wide exposure in the lay press
in the past year due primarily to a few sensational examples,
including a craniotomy in New York1 and a foot amputation in Florida.2,3
The result can be serious permanent disability or death, which
was the case in Texas when a 59-year-old patient had his healthy
right lung removed rather than the cancerous left lung.4 The $9
million settlement of the wrongful-death lawsuit following this
error of laterality speaks to the financial toll extracted.
Professional careers have been seriously disrupted as well. In
the instance of the wrong-sided craniotomy reported recently at
a large New York City hospital, the chair of the Department of
Neurosurgery was dismissed for his part in the affair.5
Hospitals themselves are also susceptible to severe sanctions.
The hospital in Tampa, Florida, where the wrong foot was mistakenly
amputated, was told to halt all elective surgery until better
procedures were established to prevent such an occurrence.6
In addition, that same institution was stripped of its accreditation
from the Joint Commission on Accreditation of Healthcare Organizations,
and consequently, Medicare funding was threatened.7
While generally not as serious, errors of laterality can occur
in the administration of anesthesia as well. An informal survey
via the Global Anesthesiology Server Network (GASNet) forum and
a mailing to ASA state component societies revealed anecdotes
of wrong-sided axillary blocks, unilateral spinal blocks and the
like. Recent correspondence by a nurse anesthetist on GASNet asked
if there were "any new and foolproof ideas" out there
to prevent such an occurrence.
Adherence to strict policies and procedures for patient identification
and surgical consent are essential elements of any preventative
solution, but no simple, fail-safe measures have come to light.
The issue of right versus left becomes much more complicated,
for example, when internal paired organs are involved.
Analysis of numerous instances of wrong-sided surgery reveals
a myriad of ways in which errors of laterality can occur.
Legal Aspects
The issue of whether or not the anesthesiologist bears responsibility
for a surgical error of laterality is controversial at best, as
was addressed in the June 1991 ASA NEWSLETTER.8
William M. Gild, M.D., J.D., an anesthesiologist and attorney,
opined that an expert witness who testified to the responsibility
of the anesthesiologist to ensure correct-sided surgery was "articulating
an expanded role for the anesthesiologist in the O.R. [operating
room] ... and setting a new standard for our specialty."
Like it or not, some states may hold the anesthesiologist responsible
for ensuring that the correct operation is done on the correct
side through regulatory law emanating from each state's health
department, which is the case in California and Hawaii. Moreover,
several institutions have adopted policies and procedures that
directly involve the anesthesiologist or anesthesia care team
in ensuring correct-sided surgery.
A computer search via the LEXIS-NEXIS service yielded little additional
information on the subject but did include a description of an
interesting case in which a group of 14 anesthesiologists were
sued by a plaintiff neurosurgeon for refusing to provide anesthesia
services after a series of surgical misadventures, including several
wrong-sided craniotomies.9 The defendant anesthesiologists
prevailed up to and including an appeal to the Iowa State Supreme
Court.
Interesting Accounts
Analysis of several surgical errors of laterality can yield insight
into how procedures and policies fail and how we might better
prevent such occurrences. Poor communication due to a language
barrier played a significant role in the wrong-sided craniotomy
that occurred in New York City. Failure to crosscheck computerized
tomography films with the patient's identification band was a
compounding factor.
A wrong-sided emergency craniotomy at another institution resulted
from poor communication of a different nature. The attending neurosurgeon
had requested that the patient be positioned "supine, head
turned, left side." The anesthesiologist and the neurosurgical
fellow hearing this request began the procedure with the patient's
head turned to the patient's left side, and therefore,
a right craniotomy was begun when in fact the staff surgeon thought
he was indicating a left craniotomy approach.
Poor communication can also lead to consequences besides wrong-sided
surgery. An aphasic stroke patient underwent a bilateral orchiectomy
rather than the indicated circumcision because of the way he responded
when addressed by the wrong patient's name, leading all to believe
he was the intended orchiectomy patient. Notably, his identification
band was removed prior to starting an intravenous line.
Failure to compare operating room schedules with surgical consents
led to the wrong-sided foot amputation that occurred in Florida.
Reliance on the patient's verbal information and failure to crosscheck
the information with respect to side of surgery is often a contributing
factor. One such case involved a bilateral renal transplant patient
who had the one functioning kidney removed because he incorrectly
stated the side of surgery.
Even when all communications and paperwork appear in order, mistakes
can occur. An unfortunate patient had the wrong leg amputated
because the attending surgeon positioned the patient prone for
better exposure to the leg vessels and then developed right/left
confusion due to the prone position of the patient.
One final anecdote of wrong-sided surgery, according to the New
York State Society of Anesthesiologists, involved a surgeon in
New York who operated on the wrong knee and subsequently stated,
"My mind was clouded by nitrous oxide in the room."
Preventative Measures
No uniformity exists as to how to best document the correct side
of surgery and prevent the confusion of this issue. Several institutions
insist on the presence of the attending surgeon for induction
and positioning, in recognition of the surgeon's key role in determining
surgical site and side. This policy is flawed by the problems
of significant surgical delays and selective enforcement of policy.
Some institutions advocate marking the patient preoperatively
with an indelible marking pencil, using an arrow or other descriptor
to indicate the correct side of surgery. The practice of writing
"NO" on the nonoperative side may be flawed by a few
factors; i.e., smudging of the word "NO" may make it
look like a mark indicating the designated surgical site, and
the word "NO" viewed upside-down appears to be the word
"ON." This second scenario resulted in at least one
instance of a wrong-sided hypobaric spinal block being performed.
Critics of the marking of patients before surgery include surgeons
and hospital administrators alike, the complaint being that they
don't like the message (presumed incompetence?) it sends to their
patients. One institution obviates this concern by flagging the
patient's chart with a bright red face sheet labeled with an "R"
for a right-sided procedure or a green face sheet labeled with
an "L" for a left-sided procedure.
Many institutions have adopted policies and procedures necessitating
several layers of crosschecking of surgical consents, patient
X-rays and chart records and direct patient questioning about
surgical procedure and side. These procedures often require verbal
agreement and signature documentation by the circulating nurse,
surgeon and anesthesiologist. Allegheny General Hospital in Pittsburgh,
Pennsylvania, requires crosschecking of consents, X-rays and the
patient's chart for correct laterality of surgery. Then, before
the scalpel is handed to the operating surgeon, a final verbal
agreement between all members of the surgical team, including
the anesthesiologist, is necessary to corroborate that the correct
procedure is being done.
Conclusion
No perfect solution exists to prevent errors of laterality. Each
institution's policy for dealing with this difficult issue will
have its own inherent bias. Some anesthesiologists will take exception
to the prospect of being held liable for ensuring that the surgeon
operates on the correct side. Many anesthesiologists already take
on this responsibility but are not aware of it. Heightened awareness
on the part of all operating room personnel as to the possibility
of such an error and rigid adherence to established procedures
for patient identification will minimize the likelihood of such
an occurrence.
Redundancy of crosschecking is desirable, and patients' concerns
about repeated questioning with respect to surgical procedure
and side should be deflected by the reassurance that "we
are all just making absolutely certain that no mistake will occur."
Care should be taken, however, to avoid confusion due to patient
sedation, age, organic disease or language barriers.
As in all other aspects of the practice of anesthesiology, vigilance
is paramount to preventing such an error.
References:
1. Altman LK. State issues seething report on error at Sloan-Kettering.
The New York Times. November 16, 1995:l.
2. Miller S. Two feet of mistakes. Newsweek. March 27,
1995:60.
3. Gauzer B. When doctors are the problem. Parade Magazine.
April 14, 1996:1-6.
4. National briefs: Wrongful death suit. Pittsburgh Post Gazette.
April 2, 1995.
5. Bloom M. Scrambled surgery. Physicians Weekly. December
25, 1995; 12(8):1.
6. Martinez J. Tampa hospital loses accreditation. Pittsburgh
Post Gazette. April 12, 1995.
7. Ryan M. Series of human errors threatens Medicare funding.
Biomedical Safety and Standards. May 1, 1995; 25(8).
8. Gild WM. Expert witness sets new standards for anesthesia practice.
ASA NEWSLETTER. June 1991; 55(6):13.
9. Locksley v. Anesthesiologists of Cedar Rapids, #51/66316
(Iowa, 1983).
Stephen R. Strelec, M.D., is Senior Attending
Staff Anesthesiologist, Department of Anesthesiology, Allegheny
General Hospital, and Assistant Professor of Anesthesiology, Medical
College of Pennsylvania and Hahnemann University-Allegheny Campus,
Pittsburgh, Pennsylvania.
Send e-mail to Dr. Strelec
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