Princess Margaret Hospital (PMH) recently released the findings and recommendations of a root cause analysis investigation on a sentinel event, which was announced by the hospital in July after a doctor performed an operation on the wrong side of an 86-year-old man’s skull. 

The Investigation Panel concluded in its findings two factors that might have contributed to the incident, and made two recommendations to the hospital to prevent the incident from happening in the future.

How it happened

The affected patient was admitted to the Neurosurgical Ward in PMH on July 12 due to a subdural haematoma. An emergency left-side burr hole operation was immediately arranged to drain out the blood. Before performing the operation, the operation side was marked on the left ear lobe of the patient by a doctor in the ward. Subsequently, the patient was sent to the operating theatre. The operating team then conducted the "Time Out" checking procedure to ensure the correct identity of the patient and the operating site.

After the "Time Out" check, members of the operating team were busy with their own tasks in preparing for the operation. The chief surgeon also needed to explain the procedure to an assistant doctor and performed surgical preparations including hair shaving and skin disinfection. The scalp incision line marking was erroneously put on the right side. The operation started after about half an hour. Yet, during that period, the operating team did not notice the incorrect head positioning and scalp incision marking, which did not match with the original operation side marked on patient's left ear lobe.

It was until the doctor saw minimal blood clotting after opening the dura on the right side during the operation, and realised that the operation was being done on the incorrect side. The doctor then closed the wound on the right side and proceeded to drain the blood clots on the left. Fortunately, the patient has been stable since the operation, and was discharged on July 24.

Perform "Sign In" and "Time Out" separately and distinctively

Subsequent to the incident, PMH appointed a panel to investigate the underlying causes and also to make recommendations to prevent future recurrence. The Investigation Panel has interviewed the staff members concerned and examined the workflow. In its findings, the Panel concluded that the following two factors are believed to have contributed to the incident:

1) The original operation site marking on the left ear lobe of the patient was not conspicuous once the doctor stood on the vertex side of the patient;
2) The correct side of the operation had not been re-checked before marking of the incision lines.

In addition, the Panel has made the following recommendations to the hospital:

1) Mark the operation site on the forehead of the patient to enhance visibility;
2a) To perform "Sign In" and "Time Out" separately and distinctively: "Sign In" involving only the anaesthetist, nurse and patient before induction, and then “Time Out” performed by the whole team just before the incision marking is made; or
2b) To perform a second "Time Out" before marking of incisions to finally check the correct operation and correct site for operation involving laterality, positioning and/or multiple operating sites.

This incident came after another brain surgery blunder in March when a neurosurgeon at Queen Elizabeth Hospital (QEH) also performed surgery on the wrong side of the brain. Findings and recommendations for the March's incident have been highlighted in the 46th issue of “HA Risk Alert” published by the Hospital Authority (HA) on 28 July. MIMS

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