Read The Following Case Study Scenario And Compose An Essay On Wrong Site Surgery
Preventing the Recurrence of Surgical Error
Abstract
Patient safety is central to quality care. The role of the quality assurance personnel in a healthcare institution is to identify gaps in care and threats to patient safety and address them using the appropriate corrective actions. In the case of Mr. Adam's unfortunate surgical event, it is clear that the preoperative procedures were not in line with the best practice standards. The root cause of this problem was the inadequate review of the patient diagnostic reports to identify the site that necessitated the operation. This could have been avoided if the doctor consulted his colleagues and carried the scans to the operating theatre. This event could attract legal action from the patient, which is detrimental to both the hospital and the surgeon. To avoid the occurrence of this mishap in the future, the hospital should, among other things, form interdisciplinary teams whose role would be the review of the patient in preparation for all surgical procedures.
Facts of the Situation
Mr. Adams developed nodules on his thyroid gland and needed lobectomy since they were prominent on the left lobe. However, the doctor conducting the procedure indicated on the patient’s file that the patient required a right lobectomy. Therefore, the entire surgical team and the patient went to the theatre for the excision of the right lobe. After the procedure, the doctor noted that the nodules on the resected organ were not as prominent as he expected. On reviewing the patient’s scan, he realized that he had removed the wrong lobe since the bigger nodules were on the left lobe.
Cause of the Problem
The major cause of this error is that the surgeon did not review the diagnostic report immediately before the theater. Ultrasound scans are fundamental in conducting the right procedure and avoiding adverse events like the one reported in this case (Paudel, Rayamajhi, Bhattarai, & Yadav, 2016). Additionally, there was an apparent lack of teamwork in the preoperative and operative phases. The surgeon did not consult with the anesthesiologist before operating on the patient. Lack of teamwork and communication has been linked to the rise in cases of iatrogenic harm to surgical patients (Mishra, Catchpole, & McCulloch, 2014). Consultation with the rest of the surgical team before theater could have increased the chance of noting the nodules on the left lobe.
Remedial Action
Taking the patient back to the theatre was not a prudent step since it could have alerted the patient to the mistake that had occurred. However, it would have immediately resolved the problem that resulted in this procedure. Operating the patient after follow-up visits would have saved the reputation of the hospital and the doctor, although the patient would still have medical issues resulting from the defective thyroid gland. If the patient learned about the mistake and had taken legal action, both Dr. Ruiz and the hospital would have lost money in litigation and risked closure or withdrawal of practice licenses.
Reflections and Recommendations
The next step in reviewing the problem is finding the root cause. After finding the root cause, the person mandated to steer quality services in the hospital would institute appropriate corrective actions. The recommended preventive actions, in this case, are developing procedure-specific preoperative checklists, encouraging preoperative consultation, and carrying the ultrasound scan and other relevant images to the operating theater. From this case, I have learned that quality improvement is a continuous practice that begins with identifying the root cause, instituting corrective action, and monitoring the effectiveness in line with the Plan, Do, Check, Act framework (Buchbinder, Shanks, & Kite, 2019).
