Previous posts have discussed the importance of following proper surgical protocol and the consequences of failing to do so. One particular component of surgical protocol that is sometimes overlooked but vital to patient safety and the avoidance of surgical errors is the pre-surgery "time-out."
Simply put, a pre-surgery time-out is a short period of time set aside before a surgery or a change in surgical teams to double-check certain items, including the patient identity, surgical site and procedure to be performed.
Unfortunately, a team of surgical residents at Yale-New Haven Hospital in Connecticut failed to conduct a pre-surgery time-out and, as a result, accidently inserted a traction pin into the wrong leg of a car accident victim.
According to the Connecticut Department of Public Health (CDPH), a patient who suffered fractures to their nose, left hip and right ankle in a car accident was admitted to Yale-New Haven Hospital.
Prior to surgery to fix the patient's ankle fracture, one surgical resident noted that the patient's left leg was shorter and internally rotated. The resident then consulted with another resident and decided to insert a skeletal traction pin to address the issue upon completion of the ankle surgery.
(Please note, skeletal traction is a procedure used by orthopedic surgeons to straighten and align bones.)
Once the ankle surgery was completed, the resident (who decided to insert the pin) signed out of the surgery and a second resident took his place. However, the second resident went on to insert the skeletal traction pin into the patient's right leg instead of the left leg.
Fortunately, the second resident later discovered the error while drafting post-operation orders and immediately fixed the issue.
Both residents later informed the CDPH that they did not conduct a pre-surgery time-out prior to the insertion of the skeletal traction pin.
After a three-month investigation, the CDPH indicated in its report that the failure to conduct the pre-surgery time-out was the proximate cause of the medical mistake. Furthermore, the report stated that proper surgical protocol dictates that a pre-surgery time-out must be performed and documented whenever an "additional credentialed practitioner is required to perform another procedure and the attending surgeon is not present during the initial time out."
A plan of correction was issued by the CDPH - outlining the need for a pre-surgery time-out in situations such as these - and was subsequently implemented by Yale-New Haven Hospital.
"We take our commitment to providing high-quality care and our reporting responsibility to the State Department of Public Health very seriously," said a spokesperson for the hospital. "On the extremely rare occasions when we fail to meet this standard, for whatever reason, we focus all of our efforts on preventing similar circumstances from occurring again."
This post was for informational purposes only and is not to be construed as legal or medical advice.
Stay tuned for more from our Texas wrongful death/medical malpractice blog ...
Wrong-Site Surgery Highlights Importance of Multiple Time-Outs (Outpatient Surgery)
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