# Presentation: 108592

## Spotlight Case May 2006

**Right? Left? Neither!**

## Source and Credits

- This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case
- See the full article at _[http://](http://webmm.ahrq.gov/)__[webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **Elizabeth A. Howell, MD, MPP**; **Mark R. Chassin, MD, MPP,***** *****MPH**, Mount Sinai School of Medicine
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*	**At the conclusion of this educational activity, participants should be able to:*
- Appreciate the role of Reason's Swiss Cheese Model in medical errors
- Understand the process of analyzing a single error
- Provide suggestions for remediation

## Case: Right? Left? Neither!

*	**A 79-year-old woman presented to an after-hours clinic with a 1-week history of diarrhea and progressive weakness. Due to signs of dehydration, the patient was directly admitted to the hospital. Past medical history was notable for stroke with residual left-sided hemiparesis, hypertension, coronary artery disease with ischemic cardiomyopathy, peptic ulcer disease, asthma, and obesity. *

## Case: Right? Left? Neither!

*	**Two weeks prior to this admission, she had developed right ankle and foot pain and had been evaluated in the emergency department (ED) of another hospital. The family was told of a possible fracture and a splint was applied. She was instructed to follow up with an orthopedist as soon as possible. Due to transportation difficulties, the patient was not seen in follow up. *

## Case: Right? Left? Neither!

*	**On physical exam, she was afebrile, appeared weak, and had a left-sided hemiparesis. The right ankle and foot was in the same splint from 2 weeks earlier. When examined, the ankle had a normal range of motion with no localized tenderness. A stool specimen collected in the ED was subsequently positive for *Clostridium difficile* toxin. At admission, a signed release of information was faxed to the other hospital to obtain records of the recent ED visit for the ankle and foot injury. *

## Case: Right? Left? Neither!

*	**The family requested an orthopedic consultation to expedite work-up. Outside records of the previous ED visit did not arrive promptly, so another x-ray was taken of the right foot and ankle. This x-ray was read by the radiologist as showing a right ankle trimalleolar fracture and dislocation. The consulting orthopedist reviewed the x-ray report then briefly examined the patient. Surgery was recommended and discussed with family, and consent was obtained. *

## Case: Right? Left? Neither!

*	**The next morning, the patient was taken to the OR and spinal anesthesia was administered. The orthopedist scrubbed and was preparing to operate. The ankle x-ray was on the view box in the OR. Prior to making an incision, the orthopedist reviewed the x-ray and was shocked to notice that it was a left ankle x-ray showing a trimalleolar fracture. *

## Trimalleolar Fracture

**Trimalleolar Fracture**

## Case: Right? Left? Neither!

*	**A prompt examination of both of the patient's ankles under anesthesia did not demonstrate any clinical evidence of fracture or dislocation. The x-ray was clearly labeled as belonging to the patient. Stat x-rays of both ankles were taken in the OR. The left ankle was intact and the right showed an intact ankle with a healing fracture of the fifth metatarsal bone. *

## Case: Right? Left? Neither!

*	**During the ensuing confusion, one of the OR technicians recalled that another patient had undergone an Operative Reduction-Internal Fixation (ORIF) of a left ankle trimalleolar fracture 2 days prior. It was later confirmed that the x-ray showing the left ankle trimalleolar fracture was mislabeled by date and belonged to the other patient who already had surgery.*

## Wrong Site Surgery

- Reliable estimates of the frequency of wrong site surgery are not available
- Data that do exist suggest these events are underreported to the voluntary sentinel events database of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as to state programs that require adverse event reporting

*JCAHO; December 5, 2001.**Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.**New York State Department of Health; February 2001. *

## Mechanisms of Adverse Events

- A single mistake, if it is serious enough, may cause harm by itself
- Organizational accidents—many smaller errors may occur, no one of which alone is severe enough to cause harm but in combination they become toxic

*Reason J. Aldershot, United Kingdom: Ashgate Publishing Ltd; 1997. *

**Notes:**
5. Reason J. Managing the risk of organizational accidents. Aldershot, United Kingdom: Ashgate Publishing Ltd; 1997. 

## "Swiss Cheese Model" of Error

- Synthesizing the work of psychologists, accident experts, and organizational sociologists, Reason provides a conceptual framework that delineates how errors made by individuals interact with system defects in complex organizations to cause harm.

*Reason J. Aldershot, United Kingdom: Ashgate Publishing Ltd; 1997. *

**Notes:**
5. Reason J. Managing the risk of organizational accidents. Aldershot, United Kingdom: Ashgate Publishing Ltd; 1997. 

## Swiss Cheese Holes Line Up

## "Swiss Cheese Model"

- Hospitals put defenses into place to prevent errors from doing harm
- Training programs; safety protocols, policies, and procedures; computerized decision support tools
- Every layer of defense has weaknesses
- Adverse events occur only when all the defenses around a particular situation have been circumvented by many errors

*Reason J. BMJ. 2000;320:768-770.*

## Case Analysis

- Which of the two causal pathways was involved?
- Single error versus Swiss cheese
- If Swiss cheese pathway was causative, which defenses failed to prevent harm?
- What remedial action might be called for?

## First Error: Communication

- Two weeks prior to admission, staff in the emergency department (ED) who diagnosed the non-displaced metatarsal fracture failed to communicate this diagnosis clearly and unambiguously to the patient and her family
- The ED physician who examined the patient and found a normal right ankle failed to communicate his or her findings to the physician responsible for admitting the patient or to the consulting orthopedic surgeon

## Second Error: Follow-up

- If the ED physician ordered the repeat foot radiographs, he or she erred further in not personally reviewing the films
- If the patient was admitted to an internist or other primary care physician, that physician also erred in not examining the patient and her x-rays

## Third Error: Mislabeled X-Ray

- Initially, an erroneous report on the patient was generated showing a right trimalleolar fracture with dislocation
- Initial erroneous report also identified the wrong side, labeling trimalleolar fracture as right instead of left

**Notes:**
Notes for speaker:
Highly implausible that the patient's actual films were misread by the radiologist as non-displaced fifth metatarsal fracture can hardly be mistaken for a trimalleolar fracture with dislocation.
Did the radiologist misread side trimalleolar fracture because order for current patient called for right foot and ankle films? 

## Fourth Error: Individual Error

- The orthopedist failed to elicit or to discover the history of the patient's previous diagnosis or treatment
- The orthopedist "briefly examined the patient"
- Surgery recommended on basis of incomplete evaluation

**Notes:**
Author notes:
By any reasonable standard of judgment, the orthopedic surgeon committed by far the most serious errors in this case. 
Unlikely that any hospital would let a patient with a displaced trimalleolar fracture (at risk for vascular compromise) leave the ED in a splint without an orthopedic consult. 
It is difficult to comprehend how even a brief physical examination of this patient's foot and ankle could not have caused this physician to question the radiographic diagnosis.

## Fifth Error: Failure to Comply with Universal Protocol

- A preoperative verification process to ensure that all studies and records are available, have been reviewed, and are consistent
- Marking the operative site
- A "time out" to conduct a final verification of the correct patient, procedure, and site **prior **to starting the procedure

*JCAHO.*

## Sixth Error: Teamwork Failure 

- Teamwork failed in the operating room
- No team members observed that the patient's ankle appeared normal
- No one questioned whether the procedure should continue

## What Went Right?

- The patient was spared unnecessary surgery at the last moment when the orthopedist discovered that the presumptive diagnosis was wrong
- The surgeon reviewed x-rays in OR after finally recognizing that the ankle he or she was "preparing to operate" on did not appear to have a trimalleolar fracture/dislocation

## Individual Error or Swiss Cheese?

- The failure of the orthopedist to perform an adequate H & P most serious error
- Second-most serious error was mislabeling of the ankle x-ray
- Many other individuals, including the staff in the first ED, the second ED physician, the admitting physician, and the OR staff had opportunity to stop this sequence of errors
- Only when all the defenses surrounding this patient failed did she experience the harm of unnecessary spinal anesthesia

## In This Case: Swiss Cheese

## Case (cont.): Right? Left? Neither!

*	**Spinal anesthesia was reversed, and the patient was returned to her room and did not have any consequences. The family received full disclosure and an apology. By discharge, a faxed copy of ED records from the outside hospital had been received. Included was an x-ray report describing a non-displaced, fifth metatarsal fracture of the right foot. *

## Near Miss or Adverse Event?

- While some might call this case a "near miss" or close call—a situation that could have led to an adverse event but did not—it is more appropriate to call this case an adverse event
- This patient was subjected to spinal anesthesia for no reason; although risks are low, spinal anesthesia is occasionally associated with severe risks such as cardiac arrest and neurological complications

*Horlocker TT. Anesthesiol Clin North America. 2000;18:461-485.*

## Remedial Actions

- Review process of identifying and labeling radiographs
- Implement Universal Protocol in all operating rooms
- Develop formal protocol to delineate precisely how responsibility for care is handed off from ED to admitting physicians and consultants
- Perform peer review of orthopedist's actions

## Take-Home Points

- Reason's Swiss Cheese Model, in which multiple errors combine to create major adverse events because of inadequate defenses, explains many adverse events in health care
- Analysis of adverse events should focus on discovering which defenses failed and bolstering them
- To prevent wrong-site/wrong-patient procedures, hospitals should implement the Universal Protocol