Originally Posted by TiredMD
Impressive that this kind of mistake could occur. Removing the wrong kidey is one thing, I understand how that kind of mistake could happen (though we always hang up the films in the OR, which pretty much elimiates the chance of operating on the wrong side as long as you can see both in the CT/MRI).
But this case is amazing.
1) A "leg operation" was probably being done by an Orthopod or Vascular. A new anus is likely done by GI or Colorectal Surgery. This means the surgeon didn't recognize their own patient, since it's unlikely they were both being cared for by the same doctor.
2) Anesthesia either didn't know what case was being done or what the name of the patient was.
3) No one talked to the patient preop about what case was being done.
4) No one noticed that there was nothing pathologically wrong with the GI tract during the surgery.
Amazing confluence of events. Kudos to all involved for the monumental screwup.
I used to work in the OR. I bet it was an 0800 procedure and the surgeon is one of those "bring 'em back have 'em draped and page me" types who was still at Starbuck's when the pt went to sleep. And the anesthesiologist didn't want to see the patient until the circulator brought the patient to the room in which anesthesia says, "Okay, any questions before you go to sleep?"
I've observed it where another nurse does the pre-op check-in and rolls the patient into the OR room where the circulator is prepping the room, so really the circulator has no idea what occurred in the pre-op interview or if one occurred. Scary stuff.
The following member says Thank You:
Would you like to comment?
