put in place to make wrong-site surgery very difficult to occur. Unfortunately, the issue is particularly pertinent in urological ureteric and renal cancer surgery, ...
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Wrong-side/site surgery BEN CHALLACOMBE, PROKAR DASGUPTA, PETER AMOROSO AND ROGER KIRBY
With the recent increased focus on patient safety, various measures have been put in place to make it very difficult to perform wrong-site or wrong-side surgery. perating on the wrong patient, side or organ is one of those events that give urological and other surgeons cold sweats and nightmares. It is something that could, and possibly should, end one’s career and is regarded in the NHS as a ‘never’ event, meaning that protocols should be in place to ensure it should never happen.
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Figure 1. Left-sided renal tumour with no external lateralising signs
Go to the Trends website (www.trendsinurology.com) to view Mike Bailey’s video on wrong-side nephrectomy
Estimated rates are around 1 in 1000 procedures.1 In the UK, the National Patient Safety Agency keeps a record of all safety incidents from surgical specialties in England and Wales, with 155 000 reported to its National Reporting and Learning Service in one year, from 1 January 2009 to 31 December 2009.2 With the recent increased focus on patient safety, a number of measures have been put in place to make wrong-site surgery very difficult to occur. Unfortunately, the issue is particularly pertinent in urological ureteric and renal cancer surgery, as the patient usually has no clear idea which is the affected side and there is generally nothing visible or palpable on examination to lateralise the problem (Figure 1). It is consequently possible to mark and
Ben Challacombe, MS, FRCS(Urol), Consultant Urological Surgeon, Guy’s Hospital; Prokar Dasgupta, MSc(Urol), MD, DLS, FRCS(Urol), FEBU, Professor of Robotic Surgery and Urological Innovation, Consultant Urological Surgeon, Guy’s Hospital, London; MRC Centre for Transplantation, National Institute for Health Research Biomedical Research Centre, King’s College London, King’s Health Partners, Guy’s Hospital, London; Peter Amoroso, MB BS, FRCA, Consultant Anaesthetist and Director, The Prostate Centre; Roger Kirby, MA, MD, FRCS(Urol), FEBU, Director, The Prostate Centre, London
www.trendsinurology.com
subsequently operate on the incorrect side if methods to ensure the correct procedure is occurring are not followed. The effect of removing a healthy kidney while incorrectly leaving a diseased one behind can be potentially fatal. When root-cause analyses have been performed in the investigation of wrongsite surgery, there are usually a number of factors that have occurred simultaneously or in sequence leading up to the incident itself. There have been cases where junior members of the surgical team have raised the possibility of wrong-side renal surgery, only to be ridiculed or suppressed by the primary surgeon. Incorrectly labelled imaging can set in motion a chain of events whereby the wrong side is repeatedly copied from clinical notes to formal letters and onto operative booking forms. While stenting the wrong ureter is unfortunate, much more significant errors regarding laterality can occur in urological surgery. Both healthy normal kidneys and functioning renal transplants have been removed in error as a result of unclear preoperative skin marking, and patients have subsequently been rendered anephric. Following the culture of the airline industry, surgeons have strived to put in place safety mechanisms to ensure these events cannot occur. SURGICAL SAFETY CHECKLIST It has been shown unequivocally, in multiple hospitals in several countries,
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Figure 2. World Health Organization preoperative surgical safety checklist
that the introduction of a checklist before surgery reduces errors, complications and inpatient deaths, even in highly performing operating theatres.3 In 2003, the Joint Commission on Accreditation of Healthcare Organizations identified three key areas that needed to be addressed to reduce the risks of wrong-site surgery: preoperative verification, site marking, and a ‘time out’ in the operating room.4 As a result of this and other studies, a validated checklist is now employed. Before all operations in every hospital in the UK since January 2009, the World Health Organization (WHO) preoperative surgical safety checklist is completed (Figure 2). This was produced by the Safe Surgery Saves Lives Study Group at the WHO and has been disseminated worldwide.3 TRENDS IN UROLOGY & MEN’S HEALTH
The checklist consists of three phases: • a sign in when the patient is checked on arrival into theatre • a time out immediately before the skin incision to ensure the correct procedure is occurring on the correct patient • a final sign out after completion of the operation. The primary aim of the critical time-out step is to ensure that the team is about to perform the correct operation on the correct side on the correct patient at the desired time. The 19-point WHO checklist was validated in eight hospitals in eight cities over a one-year period. It was found significantly to decrease perioperative death rates by half – 1.5 per cent before the checklist was
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introduced, declining to 0.8 per cent afterwards (p=0.003). The overall rates of complications also fell from 11.0 per cent of patients at baseline to 7.0 per cent after the introduction of the checklist (p
