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Having two of anything can be dangerous. It’s useful to have a spare (eye, kidney, leg) but symmetry can also lead to confusion. “Left” and “right” seems a basic distinction but, like all seemingly obvious facts, “which side” can be taken for granted, with disastrous consequences.
“Wrong-site surgery”, where the surgeon operates on the wrong person, or in the wrong place – in the worst-case scenario even removing the wrong body part – is an example of what the World Health Organisation and the NHS classify as “Never Events”. These are accidents that should never happen: not just because they have terrible consequences but also because they’re entirely avoidable. (Some insurers in the US will not reimburse hospitals for treatment arising from Never Events, for this reason.)
One of the commonest surgical mistakes is to leave something unintended behind. To avoid this, the team performs a count. Whatever the operation, before closure there will be a chant of “one-two-three-four”, as scrub nurses and operating department practitioners count tools and swabs back on to their trolley. (It may seem odd that such things can ever get lost, but blood-soaked gauze can blend into bleeding tissue quite easily; in a long operation the surgeon might get through a hundred swabs.)
As a medical student this is how you knew things were drawing to a close, as it wasn’t always clear from observing the operation itself. Watching surgery often consisted of standing mutely next to the table while the surgeon buried his hands in a hole and pulled and stapled a handful of unidentifiable viscera, all the while frowning in a way that implied he was too busy to answer ignorant questions (“Is that grey bit the stomach?” etc). We did have one fantastic colorectal surgeon who loved to explain everything. He also liked to set off his mobile after he’d finished operating. “Goddammit, I knew I’d left my phone somewhere!” he’d shout, craning over the patient’s abdomen.
In an effort to avoid wrong-site surgery, the WHO established the Safe Surgery Checklist, which is used in all British hospitals. The checklist means that someone from the surgical team should visit you before you have any anaesthetic, and draw an arrow on you with an indelible pen (“site marked”). There should be a round of introductions in theatre before the first incision, in which all the team members introduce themselves by name and role, before confirming the patient, site and procedure. It all sounds like common sense; but without such checklists, many more Never Events have been shown to occur, as people proceed by assumption – that someone else had checked that this is the correct leg; that this is indeed Jack Smith DOB 15.5.1978 and not John Smith DOB 16.6.1979.
But even with attention to detail, Never Events still happen. Department of Health figures show that, in 2011-12, 70 patients suffered “wrong-site” surgery and 41 received incorrect implants or prostheses. It is clear that minimising mistakes takes more than just lists. Surgical and medical teams need to get on well; the environment needs to be friendly enough to encourage input from all members.
I was once assisting another doctor in placing a chest drain. We had X-rayed the patient and the image was displayed on a nearby computer, for reference. The registrar was about to anaesthetise the skin when one of the medical students said, “I’m probably being stupid – but isn’t the X-ray the wrong way round?” It was.
Sophie Harrison is a hospital doctor in South Yorkshire