Question

Synopsis of events from an RCA completed on a wrong site surgery Mrs. Jackson is a 58 year old female who entered the hospital via Pre-op admissions on October 28, 2013. She was scheduled for a right knee replacement by Dr. Perez. The OR was busy and behind that morning due to an issue with humidity in the OR that required a maintenance crew to work with the system for one hour before the days scheduled cases could begin that morning. Several of the surgeons were becoming restless and verbal about the delays. Once the maintenance team completed the work on the air handling system, the OR humidity was retested and the OR rooms were re-opened. Dr. Perez insisted that Mrs. Jackson's procedure begin immediately. The nurses rushed the patient into the room. In the rush, the surgeon failed to mark the site of for the procedure. Nancy, the scrub nurse noticed but since Dr. Perez was in such a foul mood, she did not push the issue. Jack, the RNFA noticed that the knee X-rays were not on the x-ray view so ran out of the room, grabbed the x-rays from the desk just outside the room and flipped them onto the screen in the OR. In his rush, he did not use two patient identifiers to ensure the x-rays belong to Mrs. Jackson (they belonged to Mrs. Reick, who was scheduled for a Left TKR immediately after Mrs. Jackson's procedure. Once in the room, both anesthesia and Judy, the OR nurse called for a time out to check the consent, medical record and patient ID for the correct procedure, patient, site, etc. The members of the surgical team were still moving about preparing the 12 trays needed for the procedure. Judy was frustrated when she could not seem to get everyone to stop but she saw that Dr. Perez was "about to blow" so she continued with the time out. All participants in the time out confirmed that the patient was Mrs. Jackson, and that she would be having a Left Knee Replacement; no one checked the consent form. The procedure was begun and the procedure went very smoothly. It was not until the patient was in the PACU that Sam, the PACU nurse realized that the wrong site was completed. Directions As the VP of quality and risk management at the above hospital, you conducted the RCA on the above case. Discuss the following based on the event scenario above: What was the root cause(s) of the wrong site surgery? Which root causes are human factors and which were system factors? Based on the identified root causes, what opportunities do you see for improvement and what actions would you put into place to ensure that this adverse event would never happen again.

Answer 1

1) Root causes of the wrong site of procedure are,
-issue with humidity in the OR that required a maintenance crew to work with the system for one hour before the days scheduled cases could begin that morning,but he failed to do so.
-the surgeon failed to mark the site of the procedure.
-Nancy ,the scrub nurse noticed the wrong procedure but did not inform the surgeon,because of his foul mood.

2)human factors-surgeon failed to mark the site of procedure and the nurse failed to inform about wrong site.maintenance team/crew made mistake by delaying the OR maintenance work.
-system factors-work of air handling system and humidity in the OR.

3)Based on the identified root causes,OR must be kept ready one hour before the procedure.If failed to keep OR ready ,either post-poning the procedure or delaying one hour mentioning that delay of procedure because of OR maintenance.
-Surgeon must mark the procedure site promptly before entering into the OR.
-Nurse must check and inform the surgeon regarding the consent form and the x-rays of the respected patient who is planned for the procedure.
-Surgeon must recheck the procedure site and the x-rays before performing procedure.
-should not be in rush to finish the procedure without checking the basic requirements of procedure,which can avoid the mistakes and adverse events.
-Having the list of procedures in OR and the related areas like pre-operation admission areas makes aware of the procedure to all of the team members and avoids the mistakes.
-Preparation of the procedure site and marking outside of the OR also helps to avoid such mistakes.