Bob MacArthur reached out to me with a compelling story of medical error. People often wonder how a wrong-side procedure can occur in the era of Universal Protocol and two decades of "operate through your initials"/"sign your site." This story will demonstrate how. It's a real lesson in the importance of a culture of safety. Bob and I hope that you will learn from this experience.
David Ring, MD, PhD
Chair, AAOS Patient Safety Committee
On Feb. 15, 2008, I performed a wrong-side knee arthroscopy—despite having the correct leg marked, the circulating nurse questioning the information, and the performance of a time-out before the surgery. I want to share my story to raise awareness of how medical safety systems can fail and to champion efforts to catch errors before they cause harm.
The patient was a 21-year-old male professional boxer who was experiencing anterior medial left knee pain with running. Initial treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy over a 3-month period did not ease the pain. The patient was in crisis because he would not run while in pain and running was a critical part of his training.
I felt substantial pressure due to stress contagion. He had all his hopes on a biomedical, external cure and I allowed myself to take the same mindset. I ordered an MRI and even though the results were normal, I diagnosed him with a possible plica.
Looking back, I realize that choosing a controversial structural diagnosis was a move of desperation. I was thinking far too biomedically and did not fully appreciate and account for the stress the patient was feeling. He and I placed too much hope in passive, almost magical treatments. In this desperate mindset, we tried steroid injections—not a great treatment option in a young healthy knee. After 6 months of nonsurgical care, including three steroid injections, the patient remained dissatisfied.
Even though this situation made me feel very uneasy, it was difficult to resist the momentum created by this biomedical line of treatment, and I ultimately offered him surgery for a presumed plica. I now view this as an error. I normally am slow to offer surgery and try to stick to surgeries that have an excellent risk/benefit ratio. But in treating this professional athlete, I allowed myself to drift into diagnoses and treatments that were not consistent with my values.
I'm fairly sure that this is a familiar experience. In the face of persistent symptoms, we are taught to move from NSAIDs, to exercises, to shots, to surgery, even into murky pathophysiological concepts like a plica. We are not taught to recognize or address somatization of stress and distress, nor less effective coping strategies. We are not taught self-awareness, self-control, and self-compassion. These remain the elephant in the room.
I should have realized that when all a patient's dreams are in doubt, it can feel safer to say "I'm in pain" rather than "I'm in despair." Now, I talk to my patients and empathize more, I'm no longer so quick to offer cortisone shots and surgery, and I'm better at recognizing and managing when the patient's mindset is transferring to me (stress contagion).
What went wrong
On the day of the surgery, I had scheduled four knee arthroscopies, two shoulder arthroscopies, and two minor fracture surgeries in one room of the hospital's 12-room outpatient surgery center. I brought the paper charts and printed MRIs to the surgery center. The circulating nurse transferred the surgery schedule listed in the computer to a dry erase board in the operating room (OR). When I arrived I performed a preoperative evaluation and consent of the three knee arthroscopy patients who had already arrived.
I discovered that my office had mistakenly scheduled the runner for a right knee arthroscopy. This error was detected and his consent was changed by drawing a horizontal line through the word "right" and writing the word "left" in the margin. The white board in the operating room was not updated.
The surgery center protocol was for the nurse, not the surgeon, to sign the patient's thigh, not the knee. The nurse signed her initials on the left thigh, shaved and prepped the leg, and covered it with a clean blue towel.
I was talking to the second patient's family when the circulating nurse called me. She asked me which side was the correct side for the next patient's knee arthroscopy. I replied, "Just ask the patient." She responded, "OK." In retrospect, I should have realized that this was unusual and there must be some reason for confusion. I should have respected my colleague's uneasiness.
As I learned later, the patient had already been placed under anesthesia without confirmation of the correct surgical procedure by the circulating nurse, the anesthesiologist, or the scrub nurse. Amidst uncertainty, having been rebuffed by me, and fearful of her supervisor because of ongoing performance issues, the circulating nurse decided to rely on the dry erase board where she had written "right knee scope" based upon the erroneous computer schedule. She set up the OR for a right knee scope. She took the prep-towels off the left knee and shaved and prepped the right knee.
When I returned to the OR, the right knee was exposed and the remainder of the body was covered. I did not expect to see a surgical site marking due to the hospital policy of marking the limb rather than the incision site and drapes covered the thigh. I asked to view the MRIs but the prints were misplaced. I pulled the patient's chart from the stack and placed it on the counter, unopened.
I then scrubbed in and called for a time out, during which the nurse opened the chart to the consent page and held it 2 feet from me while I read through the protocol. When I read the procedure to be performed, I read through the single horizontal line that I had drawn through the word "right" and did not notice the handwritten word "left" in the margin. I requested verbal agreement to what I read, and everyone in the OR replied "yes."
I performed a right knee arthroscopy, found hypertrophic synovium, and what I interpreted as a plica with slight abrasion of the medial edge of the medial femoral condyle. My mind was so fixed on a plica that I convinced myself that there was a plica in a normal healthy knee. This is called confirmation bias. A well-functioning human mind is susceptible to confirmation bias due to its exceptional capacity for pattern formation and rationalization. To avoid psychological discord, I perceived a plica where there was not one. Everything else was normal and I closed the portals and brought the patient to the recovery room.
There, the patient noted—to his dismay and mine—that I had performed an arthroscopy on the incorrect knee. I apologized to the patient. He was too distraught to want an arthroscopy of the correct knee. I notified the hospital administrators, and 30 minutes later the OR staff and the administrators met.
The tone of the meeting was somber and professional. The events of the day were reviewed but we didn't admit our errors or discuss how to help others avoid them and catch them before they cause harm. At that time, my awareness of medical safety systems was poor.
Why it happened
This event demonstrates why the Universal Protocol is not sufficient to prevent wrong site, side, procedure, or patient events. Processes help, but what is needed is a true culture of safety in which errors are expected and systems and teams are optimized to catch them before they cause harm.
We should have used the AAOS Sign Your Site program, despite arguments from some surgeons that it would disrupt workflow if they had to sign the limb themselves and create a distraction if the ink were over the incision. I was aware of the program and regret not using it in spite of the hospital policy. I allowed the status quo to overrule my knowledge and instincts.
The OR staff did not confirm the patient's procedure prior to anesthesia and were not aware of the procedure. A pre-procedure huddle (a recommended part of the Universal Protocol) would have improved my team's ability to help me, but we had gotten in the habit of not doing it. Safety experts call this drift—working around safety protocols becomes silently accepted and the new norm. Drift is addressed by coaching to reestablish the proper norm: "I realize that this seems like a waste of time, but we've had two wrong procedures in the last 18 months, and I could really use everyone's help working to catch any errors I make. Can I please ask you to help my patient and me by following the Universal Protocol precisely?"
Communication and support are powerful tools to prevent errors. The nurse would not have called me if she knew which side was correct or if she could have spoken with the patient. I should have been aware that she was trying to tell me that there was something amiss, and I should have gone directly to the OR to address the issue. Instead, I responded in a dismissive and condescending manner. I sent a message to the team to "keep your concerns to yourself" and "don't show any signs of weakness." I now strive to set a better tone: "never worry alone" and "to err is human." We need to help each other for the patient to have the best possible result and the lowest possible chance of harm.
We can learn from the copilot on Korean Air Flight 801 who was too intimidated to remind the pilot that they were running out of fuel, leading to a crash that killed all aboard. My circulating nurse chose to risk prepping the wrong knee, rather than risk being caught and punished for not verbally confirming the procedure before the patient was placed under anesthesia. I want to make sure my copilots are comfortable speaking up about my errors and disclosing their own.
Although I would have rated my communication skills as excellent before this incident, I found many opportunities for improvement. It is important for us to be aware of how intimidating we as surgeons can be and establish quality communication with all staff. We should all emphasize the importance of nontechnical skills such as sequential levels of communication (from suggestions to commands).
I hope that this information will help others protect themselves, their staffs, and their patients from wrong site, side, person, or procedure events. As my error clearly demonstrated, the Universal Protocol and "sign your site" are helpful tools, but they are not foolproof. Surgeons—like all humans—should expect to err, and we should put substantial effort into creating a strong culture of safety. Hospital protocols such as the "time out" should not draw us into complacency, assuming that these protocols will prevent wrong site events. They should be a reminder that we are doing something dangerous with many possibilities for error and harm. In addition to strict adherence to the details of safety procedures, we need to be strong champions of safety systems.
Robert J. MacArthur, MD, is a California-based orthopaedic surgeon.
- Communication Skills Mentoring Program
- AAOS Information Statement: Surgical Site and Procedure Confirmation
- Stanton T: Beyond the Technique: Surgical Safety and the Core Competencies, AAOS Now, August 2017.