Wrong Site Surgery: Mr. Adams arrives in the preoperative area in Lincoln General Hospital for thyroid surgery.

Read The Following Case Study Scenario And Compose An Essay On Wrong Site Surgery

Read the following case study scenario and compose an essay answering the questions below. Wrong-Site Surgery Mr. Adams arrives in the preoperative area in Lincoln General Hospital for thyroid surgery. He states to the pre-op nurse that he needs the right side of his thyroid gland removed. His statement confirmed by the posting sheet, which indicated the patient is schedule for right thyroid lobectomy. The operating room nurse verifies the posting sheet with the patient statement, as well as with the anesthesiologist. The surgeon, Dr. Ruiz, confirms the right lobe is to be removed as stated in his office notes. The patient is taken to the operating room and he undergoes a right thyroid lobectomy. The surgeon finds multiple nodules in the specimen but is concerned they do not appear to be as prominent as the nodules he expected. While in the recovery room Dr. Ruiz reviews the preoperative ultrasound and realizes that the majority of the disease was in the left lobe of the thyroid. Dr. Ruiz discusses the situation with the patient’s wide and returns the patient to the operating room and removed the left lobe of the thyroid.  What are the facts of this situation?  Dr. Ruiz was faced with two choices. He could have said nothing and let Mr. Adams go home. When the surgeon saw Mr. Adams in his office for follow up, he could have told him he needed more surgery at that time. Or he could have done what he chose to do (pursue returning the patient to surgery and doing the appropriate operation). Discuss the pros and cons of both options.  Five people (the patient, pre-op nurse, OR nurse, anesthesiologist, and the surgeon) all thought the surgery was supposed to be done on the right lobe of the thyroid. What went wrong? Could this have been avoided? If so, how?  If, in fact, Dr. Ruiz performed a wrong-sided procedure, what would be the next steps in reviewing this problem? What consequences might there be for Dr. Ruiz and the hospital staff?  The heart of quality improvement and patient safety is being honest and fearless enough to look at errors in a health care organization. What kind of effective systemic approached might be used to avoid these types of scenarios? Provide your reflections and personal opinions as well as your recommendations and rationale for your responses.

Preventing the Recurrence of Surgical Error


Patient safety is central to quality care. The role of the quality assurance personnel in a healthcare institution is to identify gaps in care and threats to patient safety and address them using the appropriate corrective actions. In the case of Mr. Adam's unfortunate surgical event, it is clear that the preoperative procedures were not in line with the best practice standards. The root cause of this problem was the inadequate review of the patient diagnostic reports to identify the site that necessitated the operation. This could have been avoided if the doctor consulted his colleagues and carried the scans to the operating theatre. This event could attract legal action from the patient, which is detrimental to both the hospital and the surgeon. To avoid the occurrence of this mishap in the future, the hospital should, among other things, form interdisciplinary teams whose role would be the review of the patient in preparation for all surgical procedures.

Facts of the Situation

Mr. Adams developed nodules on his thyroid gland and needed lobectomy since they were prominent on the left lobe. However, the doctor conducting the procedure indicated on the patient’s file that the patient required a right lobectomy. Therefore, the entire surgical team and the patient went to the theatre for the excision of the right lobe. After the procedure, the doctor noted that the nodules on the resected organ were not as prominent as he expected. On reviewing the patient’s scan, he realized that he had removed the wrong lobe since the bigger nodules were on the left lobe.

Cause of the Problem

The major cause of this error is that the surgeon did not review the diagnostic report immediately before the theater. Ultrasound scans are fundamental in conducting the right procedure and avoiding adverse events like the one reported in this case (Paudel, Rayamajhi, Bhattarai, & Yadav, 2016). Additionally, there was an apparent lack of teamwork in the preoperative and operative phases. The surgeon did not consult with the anesthesiologist before operating on the patient. Lack of teamwork and communication has been linked to the rise in cases of iatrogenic harm to surgical patients (Mishra, Catchpole, & McCulloch, 2014). Consultation with the rest of the surgical team before theater could have increased the chance of noting the nodules on the left lobe.

Remedial Action

Taking the patient back to the theatre was not a prudent step since it could have alerted the patient to the mistake that had occurred. However, it would have immediately resolved the problem that resulted in this procedure. Operating the patient after follow-up visits would have saved the reputation of the hospital and the doctor, although the patient would still have medical issues resulting from the defective thyroid gland. If the patient learned about the mistake and had taken legal action, both Dr. Ruiz and the hospital would have lost money in litigation and risked closure or withdrawal of practice licenses.

Reflections and Recommendations

The next step in reviewing the problem is finding the root cause. After finding the root cause, the person mandated to steer quality services in the hospital would institute appropriate corrective actions. The recommended preventive actions, in this case, are developing procedure-specific preoperative checklists, encouraging preoperative consultation, and carrying the ultrasound scan and other relevant images to the operating theater. From this case, I have learned that quality improvement is a continuous practice that begins with identifying the root cause, instituting corrective action, and monitoring the effectiveness in line with the Plan, Do, Check, Act framework (Buchbinder, Shanks, & Kite, 2019).


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