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Unfortunately, ‘Never Events’ Still Happen

Case of the MonthThough wrong-sided surgeries have been exhaustively addressed through institutionalized precautions, they still happen. In one case, a surgeon’s stated trust in the patient apparently set in motion an ill-fated course.

A 78-year-old patient presented to a breast care center for a bilateral screening mammogram. The findings revealed a suspicious area in the right breast and an ultrasound was recommended. Several months later, an ultrasound again revealed a suspicious mass at one o’clock. Later that year, an ultrasound-guided core biopsy of the right breast at the one o’clock site returned malignant cells. An excisional biopsy detailed the intensity levels of the tumor cells.

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Early the next year, the patient and her son visited Dr. GS, a general surgeon. The initial history form showed that the patient was visiting for her “left breast . . . s/p biopsy.” In his workup that day, Dr. GS noted that the patient had been referred “for management of left breast cancer” and in his electronic record, Dr. GS further noted a “biopsy mark” in the periareolar area of the left breast but no palpable lump in either breast. Dr. GS’s note specifically mentioned the earlier mammogram: “BIRAD 4 for left breast lesion.” Dr. GS’s notes mention his discussions with the patient’s referring physician and also quote the same tumor malignancy intensity levels from the earlier biopsy, thus indicating his access to the information in the earlier workups that showed issues on the right side.

Dr. GS assessed the patient as having “invasive duct carcinoma of the upper and outer quadrant of the left breast” and offered to the patient treatment options of a needle localized partial mastectomy or a left total mastectomy, each accompanied by a sentinel lymph node biopsy. Dr. GS later prepared handwritten pre-operative orders describing the procedure as a “left mastectomy” with left axillary lymph node biopsy.

A week prior to surgery, the patient (who was not proficient in English and who had blindness in one eye) signed an informed consent for a left mastectomy and left axillary sentinel lymph biopsy. The form also described the procedure in common terms as “left breast cancer surgery.” Another consent form on surgery day also identified the left side for the planned surgery.

After the patient’s arrival and receipt of anesthesia, a “time out” was called by the circulating nurse and the type of surgery and site were confirmed by everyone in the operating room: a left mastectomy.

Dr. GS performed the surgery and sent four specimens to pathology, all of which were negative for carcinoma.

When the patient returned to Dr. GS’s office for her second post-operative visit, Dr. GS informed the patient and her son that he had performed the surgery on the wrong side (a fact that he said he learned the previous day). As Dr. GS charted his discussion that day: “I once again asked the patient about . . . what side the biopsy was done and she persistently [said] it was done on the left side.” Dr. GS also noted that he shared the biopsy and ultrasound reports, both of which showed a right-sided lesion. “I . . . accepted this is also partly my fault that I went ahead and trusted [the] patient more than the reports.”

Dr. GS apologized for the wrong-sided surgery and offered to perform and pay for a right-sided surgery, but the patient and her son declined. The ensuing legal claim against Dr. GS was resolved informally prior to arbitration.The amount of literature on preventing wrong-sided surgeries is immense. As this case shows, however, a good place to start reading is the original information in the patient’s own medical history.

 

Gordon Ownby is CAP’s General Counsel. Comments on Case of the Month may be directed to gownby@CAPphysicians.com.gownby@CAPphysicians.com