Discussion Assignment - Wrong-Site Surgery Event

Discussion Assignments assess student's ability t o a pply their learning to current t opics of interest in the field, and to share ideas and discuss with fellow students. The assignment q uest ion and evaluation details can be fo und in the attached Discussion Assignm ent document. There are two phases to this assignment

1. Read the Discussion Assignment question and prepare a 150-word response to the topic. Start a new thread to post your response to the Graded Discussi on Assignmen t forum, once it ha s opened. Once your initial thread ha s been crea ted you wi ll be able to view and r espond to other students' threads.

2. Respond to the posts of your fellow students. Part of the assig nment's marks w il l come from the quality and quantity of your discussion with other students. You m ust re spond to at least two other student threads.

Important  You will need to create your own thread before you will be able to see and reply to other student threads. Discussion Assignment Grading:

For the discussion question. you are evaluated on the fol lowing

Initial posting - 2 points

You actually posted something related to the q uestion Initial posting quality - 4 points You have offered a substantive answer to the question; substantive mean ing that you have fullv answered the question. This will usually entail references to the text s or literature, or to your professional practice experience. Follow up posting 1 - 2 points

You have provided a response to another's post (1 mark) and it is of quality (1 markl. Your posting is a substantive resp onse to another' s post; substantive meaning t hat yo u have addressed the issue in the post, as well as provided some additional points for consideration or discu ssion. This m ay entail referen ces to the texts or l iteratu re, or to your professi onal practice experien ce (i.e not just "I agree or disagree"].
Follow up posting 2 - 2 points

You have provided a response to another's post (1 mark) and it is of quality (1 mark). Your posting is a substantive r esponse to anoth er's post ; substa nti ve m eaning t hat you have addressed the issue in the post, as well as provided some additional poi nts for consideration or discussion. This m ay entail refere nces to th e t exts o r l iterature, or to your professional practice experience

Discussion Assignment Grading:

A 62-year-old man was scheduled to undergo an arthroscopy procedure. Three weeks prior to the surgery, the orthopedic clinic telephoned the hospita l to schedule the man·s procedure. At that time, the front-office staff in the clinic mistakenly scheduled a left- knee art hroscopy instead of a right-knee arthroscopy. The surgery scheduling clerk at the hospital faxed a surgery con f irmation form to the clinic. Per hospital policy, the clinic is expected to review the information on the form, verify the accuracy, and fax the signed confirmation back to t he hospital. The clinical staff was busy and did not fax the confirmation back. On the day of the surgery, the patient"s paperwork indicated that the surgery was to be performed on his left knee, per the original phone call from the clinic. The surgery schedule, a document used to plan t he day's activities in the operating area also indicated that the patient was to have a left-knee arthroscopy. The man was taken to t he preoperat ive holding area, where a nurse spoke with him about his upcoming procedure. Relying only on the surgery schedule, the nurse asked the patient to confirm he was having an arthroscopy on his left knee. The man told the nurse that he had been experiencing pain in both knees and that he'd eventually need procedures on both of them. He thought he was scheduled for surgery on his right knee that day but that perha ps the doct or had decided to ope rate on his left knee instead. The nurse did not read the history an d physical examination report that the patient's doctor brought to the hosp ital t hat morning. If she had rea d this report, she would have noticed that it indicated rig ht knee surgery was scheduled that day.

The anesthesiologist examined the patient in the preoperative holding area. When asked about the procedure, the man was confused about which knee was to be operated on that day. The anesthesiologist wrote "knee arthroscopy"· in his notes in t he patient"s record. The patient was taken into the operating room, where t he surgeon was waiting. The surgeon spoke with the patient about the upcoming procedure on his right knee, and the patient signed a consent form indicating that the surgery was to be performed on the right knee that day. The surgeo n marked his initials on the man·s right knee in ink to designat e t he surgery site. Th e anesthesiologist and scrub nurse r eadied the room for t he procedure. Th e patient was anestheti zed and fell asleep. Thin king that the man wa s having surgery on hi s left knee, the nurse placed a drape over his right knee, not noticing the surgeon·s initials. The left knee was placed in t he stirrup and prepped for the procedure . The nurse then asked everyone in the room to confirm that the man was the correct patient and that he was havi ng an arthroscopy on his left knee . Everyone in the room said "yes" except the surgeon, who was busy preparing for the procedure. Distracted, he nodded his head in agreement. The nurse documented on the preoperative checklis t that the pa tient's identity, procedure, and surgery si te had been verified.

The surgeon performed the arthroscopy on the knee t hat had been prepped - the left one . When the patient awoke in the surgical recovery area, he asked the nurse why he felt pain in his left knee and told her that the procedure should have been performed on his right knee. The nurse notified the surgeon, who immediately informed the patie nt and family about the mistake. Answer the following questions in your initial discussion post

1. Describe the at least three causal factors that contribute to the wrong site surgery.

2. Who would you include in activities to perform a Root Cause Analysis?

3. Using Root Cause Analysis, document what you consider to be the most signi f icant cause of this event. Explain why you selected this cause.

4. Following the Root Cause Analysis, what should the next steps be for the hospital?

5. What other tools or processes might be used in investigation of, or response to, this issue?