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Wrong Site Surgery Case Study: Investigation, Causes & Prevention – Report
| University | University of York (UOY) |
| Subject | Health & Safety Incidents |
Case 5: Wrong Site Surgery
Patient A is a 30 year old male who was referred to the Dermatology department by his General Practitioner (GP) on 13 July 2020. On referral Patient A had multiple naevi (moles) on his back, and a few were noted to be suspicious. Patient A had never suffered skin cancer and has no family history of it. Patient A was referred to Dermatology via the Two Week Wait (2WW) Cancer Exclusion Service and a clinic appointment was arranged for 26 July 2020.
When Patient A attended the clinic, the Dermatology Registrar (Doctor 1) noted that there was a 5 x 5mm ill-defined naevus with a pale centre on his right upper back. The plan was for excision of this naevus in case it was dysplastic. Dysplastic naevi are unusual-looking benign (non-cancerous) moles, which may resemble melanoma (skin cancer), and people who have them are at increased risk of developing melanoma in a mole or elsewhere on the body. Patient A was consented for the procedure and an appointment for the surgical excision of the naevus was to be posted to him.
However, Patient B a 58 year old male was instead sent an appointment letter on 27 July 2020 from the service. The appointment invited Patient B to attend for a minor surgical procedure on 15 August 2020. This appointment letter was sent erroneously as it was in fact intended for Patient A.
Coincidently, Patient B had an itchy naevus in the same area on his back as Patient A. Patient B had seen his GP six months previously and at that time the GP did not feel that a dermatology referral was required and so the plan was to monitor the naevus. Therefore when Patient B received the appointment for 15 August 2020, he assumed that his GP had made the referral and he was happy to attend the appointment.
The medical notes were not available to the service on the day of the procedure. The investigation team established that there are frequently notes missing for the Dermatology clinics, especially when patients are seen originally in outlying clinics. Coincidently both Patient A and B live in the same town in which the Dermatology service provides an outpatient clinic, which is why Doctor 2 was not unduly surprised that there were only temporary notes available and he was reassured by what Patient B had told him on the day of the procedure.
Initial investigation indicated that
- An appointment for a minor surgical procedure had been sent in error to Patient B instead of Patient A.
- On the day of the procedure, temporary medical records were incorrectly prepped and later found to contain documents for both Patient A and B.
- Inadequate identity checks were performed at the time of the minor surgical procedure.
This resulted in Patient B undergoing a minor surgical procedure that was intended for Patient A. Patients A and B are both male and shared the same surname and the first four digits of their post codes, but no other personal details were similar.
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Timeline of Events
| Date | Event | Comments |
|---|---|---|
| ||
| 13/07/20 | Referral registered via Electronic Referral System for Patient A. | |
| 14/07/20 | Appointment reviewed by 2 Week Wait administrator. Appointment letter sent out for appointment on 26/07/20. | |
| 26/07/20 | Patient A attended the 2 Week Wait Dermatology Clinic appointment. Diagnosis: atypical pigmented lesion right upper back possibly dysplastic listed for excision. Consent form completed by SPR that assessed Patient A in clinic. Patient consent form had correct addressograph (identity sticker) on for Patient A. | Patient A had signed the consent in the Health Professional box by mistake and it was not dated. Site of excision not stated on consent form. |
| 27/07/20 | An appointment letter was sent to Patient B asking him to attend for a surgical procedure on Tuesday 15 August 20 at 09:00hrs. Patient B was listed on the biopsy list. | The Clinic Coordinator’s statement says the casenote number was incorrectly entered which in turn brought up the wrong patient. At a glance both patients had the same surname and both lived in the same town. Patient B had previously been seen by his GP about a lesion on his back, and assumed that his GP had referred him to have the lesion removed and therefore attended the appointment. Patient B had the same surname and the same 4 digits of postcode as patient A. |
| 10/08/2020 | Highlighted by Cancer Pathway Navigator that Patient A was listed for a minor surgical appointment but an appointment had not been made. | Service contacted patient A by telephone and an appointment was made for 21 August 2020 ensuring that the 31 day target was not breached. |
| 15/08/20 09:00hrs | Patient B attended the appointment. Documentation available to the surgical team on the day of procedure was
The procedure was carried out uneventfully and patient B left the department with a follow up in a virtual clinic. | Consent process not correctly followed. When the doctor performing the biopsy checked the consent form; he failed to pick you that the addressograph details on the consent form were for Patient A and not for Patient B. Histology: Punch excision of skin from right upper back- benign dysplastic naevus with mild atypia, 0.3mm to peripheral margin. |
| 16/08/20 Morning | Error came to light when the clinic clerk was doing the outcomes for the clinic the previous day and came across Patient B’s 4 week Virtual Clinic appointment. When trying to book Patient B onto the appropriate Virtual clinic it was realised Patient B had never been referred to the department. | |
| 11:00hrs | The clinic coordinator notified the Admin Manager. | |
| 12:00hrs | Patient A rang and given an appointment for 21/08/20 for the excision of the lesion on his right upper back. | |
| 12:30hrs | The Admin Manger notified the Head of Service. The Admin Manager was tasked with investigating the facts of this incident. | No Datix form completed at this point in time |
| 13:00hrs | Patient B was contacted by the Admin Manager in order establish how Patient B was referred to the Dermatology service. Patient B explained that that he had been to see his GP 6 months prior with an itchy mole. The GP advised that they would keep an eye on the mole. When receiving the appointment letter Patient B assumed that his GP had made the referral. | Patient B did explain that the doctor who carried out the biopsy was unsure of which part of the anatomy the biopsy was to be taken from. |
| 19:30hrs | The Admin Manager reported back to the Head of Service. Head of Service asked for the Admin Manger to speak with the doctor involved on the following day. | |
| 17/08/17 11:00hrs | Admin Manger contacted doctor that carried out the biopsy | |
| 13:00hrs | Doctor involved spoke with the Admin Manager to discuss the incident. | |
| 21/08/20 12:00hrs | Patient A attended the biopsy appointment. A new consent form was completed and procedure carried out. Patient A was discharged with a virtual appointment booked for 13/08/20. | Histology: right upper back lesion- moderately dysplastic compound nevus |
| 13:30hrs | The General Manager spoke to the Head of Service (to discuss other issues) and this incident was mentioned but it was felt that further information was required. | |
| 22/08/20 14:30hrs | Patient Safety Lead visited the General Manager’s office and this incident was mentioned. | |
| 15:15hrs | Confirmed that this incident was Never Event. Escalated to Head of Operations. | |
| 23/08/20 | General Manager, Admin Manager and Clinic Coordinator met to gather further information and a Datix was raised at 10:00hrs. | |
| 24/08/2020 | Consultant Dermatologist spoke to Patient B to explain that:
| Consultant spoke to the doctor, who performed the biopsy, although the mole was not overly suspicious, it was atypical enough to warrant a biopsy. |
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Exercise
You will in effect re-investigate this incident and then present the findings in your learning groups on 21/03/23.
Everyone needs to contribute to the presentation and I would ask you to start with a brief summary/ overview of the incident.
Points to address
- What information do you need to gather for this type of investigation and why?
- Looking at the summary and the timeline what do you think went wrong?
- What is the procedure that should have happened? – think A&P
- What were the route causes / most basic cause/s of this incident?
- Why did these things go wrong?
- Think personal/ environmental/ educational – so human factors
- You will need to see if there were policies/ guidance that should have been followed, if there was what did the guidance say?
- What could be done to prevent this happening again?
- What needs to be done to care for the patient and the staff involved?
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