Question

A Case Study-Utilizing Root Cause Analysis Amputating the Wrong Extremity-(Left Leg) Mr. James came to the hospital.to have.an.electedorthopedic surgical procedure. Mr. James is.a fifty year old who has suffered with osteoarthritis for many years and has a tendency to form blood clots in the lower leg. Recently the disease has become more crippling to him and the skin has broken down and become gangrenous and infected. His surgeon and he decided to do a right leg amputation. On the surgical day, there was a staffing issue in the operating room. The nurse routinely assigned to do the orthopedic cases was absent. The procedure for admission into the OR is called "Time Out". This involves everyone on the team, for that procedure, to double check each other as they perform their surgical duties and prepare the surgical site, in this case, the right lower leg for amputation. The circulating nurse, assigned to this patient, goes to the Holding room and receives the patient. She asks his name, date of birth, the procedure that's to be done, as the patient understands it and reads his chart number out loud so that the attending anesthesiologist hears it. He now reads the number out loud and then they both read it on the chart. They confirm with the patient which extremity is to be amputated. The surgeon should have marked the leg the night before. The consent form is checked for accuracy. The patient is told to undress and is given a hospital gown to put on and is placed on the stretcher to go to the OR. In the OR, the patient is anesthetized and positioned on the OR table for surgery. The intern preps the leg and drapes him with the surgical drapes. The OR table is turned and now the orientation has changed. Somehow the surgeon did not check for the correct limb to be amputated. Both legs are draped and the operative one was not suspended from a leg support, as was the usual routine, and the third "Time Out" was not done. Then it is found, that the leg was not marked preoperatively by the surgeon. Errors: , 1. No third "time out" was done by operative team nor was consent checked again in OR room 2. The intern should not have prepped the patient. (duty of pt year or chief resident) 3. The surgeon did not mark the operative leg 4. Nurse assigned to-the room did not know how to work in an orthopedic room 5. The operative leg should have been supported on a leg rest while being prepped 6. Surgeon should have been made aware of the table being turned

Establish new policy and procedure for this procedure

Decide who should lead the team investigation of this error

Who should be on the team.

Trace all errors that occurred.

What is your solution to preventing this error.

note: the answer must be in fish bone format. thank you

Answer 1

These are the primory problemes associated with the surgical site error, instead of right leg his left leg procedure done.

1. No third "time out" was done by operative team nor was consent checked again in OR room

2. The intern should not have prepped the patient. (duty of pt year or chief resident)

3. The surgeon did not mark the operative leg

4. Nurse assigned to-the room did not know how to work in an orthopedic room

5. The operative leg should have been supported on a leg rest while being prepped

6. Surgeon should have been made aware of the table being turned.

Establish new policy and procedure for this procedure

1. Implement a checklist
2. Watch for miscommunication during hand-offs
3. Think outside the operative room
4. Involve everyone- patient included
5. Keep the surgical instruments in the back of the room until completion of the time out
6. double check with ward staff before taking the patient to OR
7. record and report surgen to mark the surgical site previous day itself
8. Make sure your doctor initials your site
9. confirm the surgery site with the surgeon right before the procedure

Decide who should lead the team investigation of this error

From the quality department lead the investiagation of this error

Who should be on the team,Trace all errors that occurre, What is your solution to preventing this error.

In the team Surgen, scrub nurse, quality staff, Incharge doctor, anesthetist , other staffs those who involved the surgery, advocate.

Errors occured because mainly the surgen did not marked the surgical site, he is not aware of the change in position of surgical table, no third time out called, nursing staff is not experienced in orthopodic surgeries, anesthetist given anesthecia before confirming surgical site, intern prepaired both the legs,Consent did not cross checked . These are the possible errors occured.

What is your solution to preventing this error.

Follow these steps.

1. Implement a checklist
2. Watch for miscommunication during hand-offs
3. Think outside the operative room
4. Involve everyone- patient included
5. Keep the surgical instruments in the back of the room until completion of the time out
6. double check with ward staff before taking the patient to OR
7. record and report surgen to mark the surgical site previous day itself
8. Make sure your doctor initials your site
9. confirm the surgery site with the surgeon right before the procedure