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The safety checklist
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A series of errors resulting from negligence in following the safety checklist
Following a lateral ankle ligament injury on the right side, a patient undergoes an anatomical ligamentoplasty performed arthroscopically.
During the pre-anesthetic consultation, no contraindications are noted. The intervention is planned under general anesthesia with outpatient care, a protocol accepted by the patient.
The medical staff does not perform hair removal or marking around the area to be operated on, and the patient is taken to the operating room.
The patient is placed in the induction area and greeted by the Anesthesiologist-Intensivist (AI). He undergoes preoperative interview by the operating room nurse, in the presence of the AI: confirmed identity (identification bracelet), side to be operated on (Right) confirmed, fasting, allergies. The surgical intervention is carried out without difficulty, the patient is awakened, and transferred to the Recovery Room.
Upon awakening, the patient realizes that the wrong ankle has been operated on; the medical team operated on the wrong side.
The surgeon in charge acknowledges the mistake and explains that the operation was performed because the left ankle showed lesions consistent with the diagnosis given.
The consequences of this error:
• The patient underwent a unnecessary operation and must undergo a second surgery.
• He chooses to have the second surgery performed at another facility, having lost confidence in the team in charge.
• Rehabilitation will take much longer.
• A second sick leave prescription is required
• The patient requests compensation through a civil procedure, which the court grants.
Barriers that did not work and allowed the incident
• Identity verification: the individuals responsible for the patient's setup did not perform an identity verification check.
• Partial transmission - to only a portion of the team - of information regarding the patient permutation compared to the program planned by the surgeon.
• No marking of the operated limb prior to the intervention: neither in outpatient care nor during the preoperative interview.
• The healthcare professionals who conducted the preoperative interview were different from those who carried out the surgical setup.
• Lack of final verification of this last point before incision (time 2 of the checklist).
Barriers that were respected but did not prevent the incident
The side to be operated on was indeed:
• indicated on the operating room schedule
• mentioned in the patient's anesthesia file.
• checked during the preoperative interview upon arrival at the operating room.
Areas for reflection and/or improvement
• Healthcare professionals who verified the elements of the file should take the lead on certain technical actions, especially patient setup.
• Marking the side to be operated on should become standard practice for paired organs.
In conclusion
Taking the time to conduct a situation briefing allows for identifying vulnerabilities and detecting elements that do not conform to the care processes.
Every minute dedicated to risk management is an investment that yields significant returns for patients. Additionally, it also yields benefits for healthcare professionals, for whom the impacts are rarely neutral.
Communication among healthcare professionals must be a priority.
The human factor remains at the heart of risk management.