A Boston surgeon who performed the wrong procedure on the hand of an elderly woman has disclosed the excruciating details of his error in one of the nation's most prominent medical journals.
As usual this case had all of the classic error-inducing factors:
The procedure was done at the end of a long day;
Stress was high because several other surgeons were behind schedule. When surgeons are stressed, the surgical team is stressed;
The patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment;
The surgeon didn't have a habit of leading or actively participating in the Time Out (seeing them as an unnecessary burden);
There were communication issues as the patient didn't speak English.
The surgeon did speak Spanish and spoke to the patient in that language. This exchange in Spanish was mistakenly interpreted by the Circulator in the room as a “Time Out,” the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred.
While admittedly I wasn't there for this event, I have personally observed many other OR situations like this one, and I have no doubt that the nurse did an internal debate with herself about whether she should speak up and question the surgeon about the Time Out and the need to do it in English for the benefit of the team. For whatever reasons, including the stress she felt from the surgeon and the fact that the surgeon didn't typically lead, or get actively involved in the Time Out, she decided it was okay to let it slide.
If the surgeon had always made it a habit of leading the Time Out, and of making a safety statement at the end of it encouraging his team to speak up if they saw something not in the patient''s best interest, it would have made it easier for the nurse to speak up.
A classic, effective, stop-the-line assertive statement by the circulating nurse at that moment would have changed everything.
He didn't, and she didn't. The result was the surgeon performed a carpal-tunnel-release operation, instead of a trigger-finger-release procedure.
What did the surgeon learn? “I no longer see these protocols (the Time Out) as a burden. That is the lesson,” he said.
It is unfortunate that so many see the proper execution of a Time Out as an unnecessary time waster until "it" happens to them.
Experience is a great teacher, but she sends in terrific bills.
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