Wrong side/omitted procedure

  1. 0
    Had a question for you all. I recently had surgery and while in the preop holding room, was given a consent form to sign. This consent form had the wrong side and omitted one of the procedures. I notified the nurse of these issues who told me that she couldn't get the consent form changed nor could I speak with the surgeon until I was in the anesthesia room. She said I was required to sign the errant consent form before she could move me down to the anesthesia room. If I didn't sign, I could not have the surgery.

    I felt at a loss so I signed the consent form with the wrong side, and omitted procedure, then moved down to anesthesia where I spoke with the doc and got the consent form rewritten and signed (prior to me being given anesthesia).

    I had also figured that once I got on the table I could make sure I was positioned to ensure they were doing the correct side, but I was given anesthesia while being wheeled into the room, and my last memory is of entering the operating room, so I was out before I was transferred to the OR table.

    I had a few questions for you all. I was wondering how often consent forms have the wrong side listed on them? I was also wondering why I was required to sign an incorrect consent form before I was allowed to speak with the doctor? I was really concerned that they'd accidentally use the bad consent form in the surgery And is it usual to be knocked out before even being put on the OR table?

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  2. 25 Comments...

  3. 3
    You should have NOT signed the wrong consent!!! It is your right as a patient to speak with the doctor prior to signing your consent and your experience is exactly how wrong site surgery occurs!!! Being an OR nurse I always make sure you have all your answers questioned prior to moving into the OR. As far as being medicated anesthesia gives you versed if all is a go and you usually don't remember anything even if you were awake.
    ORoxyO, LockportRN, and BuckyBadgerRN like this.
  4. 1
    I don't know why they would have you sign an incorrect consent form. In the future I would ask to speak with someone first. You would hate to wake up and find out the wrong surgery was done.
    Goobstress likes this.
  5. 1
    That sounds like someone who just didn't want to deal with the problem. You should never be asked to sign an incorrect consent. Where I work, if there's any discrepancy between what the patient says/what the schedule says/what the consent says, there is no moving on to the next step. The proper thing for the nurse to do would have been to page the surgeon for clarification and to correct the consent. As for being knocked out before moving to the OR table, I'd guess you were given an anxiolytic with amnesic properties (such as Versed/midazolam) rather than full out general anesthesia.
    LockportRN likes this.
  6. 1
    I agree- I would never have a patient sign an incorrect consent form!

    Also, with surgery, it has always been my experience that the SURGEON obtains consent, anesthesiologist anesthesia consent, etc. When I had surgery myself, it was the resident who went over and obtained consent from me. When I worked with surgical patients, it was always the MD/NP who went over the consent with the patient and had them sign it. Now, we as RNs obtain consent for blood/central line placement/etc...even that makes me nervous though, and I don't think that it is right that they force us to do that.
    Goobstress likes this.
  7. 0
    Never sign something that isn't correct. If you signed it and they did it incorrectly but you had given the ok, you would be up a creek without a legal leg to stand on. Remember the old, "if it's not written, it didn't happen"??

    I went to the doctor 2 weeks ago. I had completed my first appointment history information ahead of time but was asked each and every question anyway. Then, the doctor, using the computer that had the information entered on it, told me things I had supposedly said about my family history, allergies, and reason for being there that were nowhere near what I had said. For instance, I was there for leg pain but the reason was listed as fatigue. I have big medication allergies, but none were listed even though I had them on the paper I completed and the person who asked me was told about them. I asked the doctor if she had the right chart. She checked. Yup, it was me.

    Later that week I explored the website that was supposed to have test results for the labs, xrays, and doppler study I had done. Those were all ok, but my diagnosis had nothing to do with what I had gone to see the doctor for. I do not have confidence in this doctor's office. I doubt I'll go back...

    Sorry for the soapbox--had to get that off my chest.

    Truly, though, don't let being told you "have" to do something make you do it. You have some extreme rights.
  8. 4
    Holy CRAP, really?! That is all kinds of wrong!

    Everyone else has pretty much covered it, but I'm going to go a step further and say take it up to management. The fact that the surgeon was not there while you signed the consent, and the BS the nurse spouted about you being "required" to sign a wrong consent, is absolutely unacceptable, and their bosses need to know about it.
    ORoxyO, LockportRN, NicuGal, and 1 other like this.
  9. 3
    Quote from ayvah
    had a question for you all. i recently had surgery and while in the preop holding room, was given a consent form to sign. this consent form had the wrong side and omitted one of the procedures. i notified the nurse of these issues who told me that she couldn't get the consent form changed nor could i speak with the surgeon until i was in the anesthesia room.

    i find this very hard to believe. the nurse might have been new, or perhaps she just didn't want to page the surgeon to come fill out a new consent with the correct info. an incorrect surgical site listed on the consent is a sentinel event:

    "a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. serious injury specifically includes loss of limb or function. the phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. such events are called "sentinel" because they signal the need for immediate investigation and response." -the joint commission

    furthermore, you should have been marked with the surgeon's initials on the correct site. many times, this is done in the pre-op holding room.

    of course you could have spoken to the surgeon prior to going to the anesthesia room. i imagine if the surgeon heard this excuse from the nurse delivering this message to you, s/he would have been irate. it's not like you are knocking on the giant door to oz and asking to a funny looking guy with a cartoonishly large mustache to speak with the wizard. i have never heard anything so ludicrous!

    she said i was required to sign the errant consent form before she could move me down to the anesthesia room.

    wrong, wrong, wrong. you have got to report this to risk management. this is beyond wrong, and i can't believe this was allowed to happen. it sounds like plain ol' laziness to me, and this nurse needs a serious sit down convo with her nurse manager. no hospital would ever advocate this practice.

    if i didn't sign, i could not have the surgery.

    if you didn't sign the correct consent form, you couldn't have the surgery. again, this is serious and i implore you to take this up with risk management. can you imagine what a layperson would feel like in this position? many pts feel so stripped (literally and figuratively) while in pre-op holding, that they will sign anything because they trust that we as medical professionals have all of our ducks in a row. you recognized that it was the wrong site and that a procedure was omitted, but you can probably understand how a scared and nervous pt wouldn't even read over the consent.

    i felt at a loss so i signed the consent form with the wrong side, and omitted procedure, then moved down to anesthesia where i spoke with the doc and got the consent form rewritten and signed (prior to me being given anesthesia).

    thank goodness for that! but the process this hospital uses is very dangerous.

    i had also figured that once i got on the table i could make sure i was positioned to ensure they were doing the correct side, but i was given anesthesia while being wheeled into the room, and my last memory is of entering the operating room, so i was out before i was transferred to the or table.

    yep. good ol' versed will do that to you!

    i had a few questions for you all. i was wondering how often consent forms have the wrong side listed on them? i was also wondering why i was required to sign an incorrect consent form before i was allowed to speak with the doctor? i was really concerned that they'd accidentally use the bad consent form in the surgery and is it usual to be knocked out before even being put on the or table?
    it is typical to have 1-2 mg of versed prior to being rolled back to the or. since versed has a retroamnesic effect, you probably felt that you were knocked out, but in reality, you were likely talking, helping the staff by moving to the or bed yourself from the stretcher, but just don't remember doing it. i have never seen a pt so groggy from pre-op doses of versed that we had to move them over to the bed ourselves. after emergence, that would be a routine practice, but not before induction.
  10. 3
    Oh my....I would have never signed and said, Well I guess my surgery is off, you care to go tell the surgeon why? I would be calling their head nurse and then contacting their risk managment department about this.

    Where I work, the surgeons usually come to the holding room right before going to scrub in to touch base with the patients. Guess we are lucky that way!
    Goobstress, LibraSunCNM, and LockportRN like this.
  11. 1
    Based on your previous posts and thread. I find it highly "unlikely" that the incident occurred. As a Perioperative Nurse of over nine years, I am highly offended that you would fabricate a story about your rights and safety being violated. That a nurse would refuse for you to speak to your surgeon or clarify the procedure. Besides, based on your participation with the website...why "would" you allow it? Seriously, I stand behind my fellow OR nurses. If its attention you want, I suggest adopting a puppy.
    aliciaRNBSN likes this.


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