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Sunday, August 26, 2007

The neurosurgeon relied on memory, not the CT Scan: Wrong site brain surgery

An 86-year old man, who has not been identified, came to the emergency department at a hospital in Rhode Island on July 30 with increasing lethargy three days after a fall. A CT scan indicated he had bleeding on the left side of his brain, and he was transferred to the operating room for surgery to drain the blood.

A nurse practitioner did not record which side needed surgery in the patient’s medical history nor on the consent form signed by the patient’s relative.

When a different nurse — a circulating nurse in the operating room — pointed out that the information was missing, the surgeon wrote down the side where he would operate on the consent form.

The surgeon didn’t confirm his memory by checking the CT scan, health inspectors found. He wrote down the wrong side on the form, and then cut open the wrong side. When he realized his error, he operated on the correct side.

The patient 86-died Saturday, and the medical examiner's office is still trying to determine whether the surgical error contributed to his death.

The hospital's chief quality officer said that the staff's sense of urgency about caring for the patient had superseded the rules.

Of course, as the quality officer added, emergencies are "exactly where policies and procedures need to be as tight as possible."

Cooper said that she believed someone in the operating room had questioned whether the correct side was being cut, but the surgeon was confident he was right.

Advice: Elderly hospital patients should bring an advocate.

Read another wrong side surgery story, or read more from the source article by Felice Freyer in the August 24 issue of the Providence Journal.

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