A male patient aged 69 years was admitted for
removal of his chronically diseased right kidney
(nephrectomy). Due to a clerical error, the
admission slip stated “left”. The operating list
was transcribed from the admission slips.
The patient was not woken from sleep to check
the correct side on the preoperative ward round.
The side was not checked with the notes or
the consent form. The error was compounded
in the operating theatre when the patient was
positioned for a left nephrectomy and the
consultant surgeon put the correctly labelled
X-rays on the viewing box back to front.
The senior registrar surgeon began to remove
the left kidney.
A medical student observing the operation
suggested to the surgeon that he was removing
the wrong kidney, but was ignored. The mistake
was not discovered until two hours after the
operation when the patient had not produced
any urine. He later died.
Questions
– Identify the opportunities for checking the site
of surgery.
– Why do you think the surgeon ignored
the medical student?
– Discuss whether the surgeon’s actions were
a violation or a system error
