HealthGov Conference 10-11 December 2007 “CASE STUDY – REMOVAL OF THE WRONG BREAST” The uneasy balance between systematic/individual responsibility Helen

HealthGov Conference 10-11 December 2007

“CASE STUDY – REMOVAL OF THE WRONG BREAST”

The uneasy balance between systematic/individual responsibility

Helen TurnbullLegal Manager, Disciplinary Services10-11 December 2007

CASE STUDY REMOVAL OF THE WRONG BREAST

History

• GP found lump in Left breast. Referred for investigation.

Bilateral Mammogram

& Ultrasound Report - Irregular 14mm lesion lying at the 3 o’clock position 5cm from Left nipple.

Primary breast cancer.

Referred to Surgeon

• Surgeon found palpable 2cm lump at the approx 2 o’clock position some distance from the Left nipple.

Opinion – Highly suspicious of malignancy

• Surgeon took a fine needle aspiration biopsy (FNAB); provided National Breast Cancer Centre material; drew illustrations; discussed options/risks/complications.

• FNAB confirmed the malignancy.

• Decision - Mastectomy.

CASE STUDY – REMOVAL OF THE WRONG BREASTCASE STUDY – REMOVAL OF THE WRONG BREAST

Mistakes

Mistake 1

• Admission Request/Consent Form.

Surgeon wrote ® rather than L

Mistake 2

• Surgeon did not have patient’s medical records before him when filling out Admission Request/Consent Form.

Mistake 3

• Surgeon did not have own medical records in operating theatre.


Result

The patient’s Right breast was removed instead of the Left.


Swiss Cheese Model

• 78yr old patient suffering from severe dementia and could only speak Russian

1st consultation accompanied by her daughter

1


Swiss Cheese Model (cont’d)

• Decided that unfair on patient to return to surgeon’s rooms so the daughter agreed to attend to pick up the Admission Request Form.

• Son-in-Law instead attended during a particularly busy morning session.

• Surgeon filled out the Admission Form at the receptionist desk in between appointments without consulting his clinical records.

2



• Patient did not attend pre-admission clinic 3



• No formal admission clerked by a RMO

4



• Entry made in the nursing notes in the

hospital records was for a ® mastectomy nurse copied the Admission Form.

• Nursing home details faxed to hospital were not attached to hospital records

5



• Daughter did not accompany patient to operating theatre

• No formal handover by ward nurse to theatre

• Surgeon did not conduct physical examination

• X-rays were not in the theatre

6



WRONG BREAST REMOVED

• Normal Registrar was running late, another Registrar filled in. Patient was already draped

with ® breast exposed. Registrar was asked to do surgery.

• Registrar assumed all cross checks had been done.



Surgeon’s Responsibility

• At all times the Surgeon accepted full responsibility for the error.

• Spoke frankly to the family and sincerely apologised.


Hospital’s Responsibility

• Open honest and timely investigation by the hospital.


Changes to the Hospital Practice

• Improved Consent Forms returned to VMO if incomplete procedure, side & site printed

• Special Needs patients alert on admission

• Patients not attending pre-admission clinic to have mandatory medical admission.


Changes to the Hospital Practice (cont’d)

• Improved checking system at all points of entry.

• Correct side & site check list College Department of Health

• JMO/RMO to ensure imaging/pathology in theatre.


Changes to the Surgeon’s Practice

• Doctor’s own notes present when completing Admission Form.

• Doctor’s own notes in theatre.

• Doctor’s independent confirmation in theatre:

Phoning the daughter

Examining the patient after sedation

Consulting admitting officers

Ensuring x-rays in theatre


Accountability/Punishment

Redesigning systems to reduce error

Annals of Internal Medicine

17 June 2003



Redesigning systems to reduce error

Accountability/Punishment

Uneasy balance between systems error and individual responsibility

“Was everything as safe as it could have been?”

She asks quietly

• Open disclosure.

• Local climate of psychological safety.

• Leadership.

• Look beyond the individual error.


THE ENDTHE END

Documents

HealthGov Conference 10-11 December 2007 “CASE STUDY – REMOVAL OF THE WRONG BREAST” The uneasy balance between systematic/individual responsibility Helen