Citation

Hanchanale V, Rao AR, Motiwala H, Karim OMA. Urol. Ann. 2014; 6(1): 57-62.

Copyright

(Copyright © 2014, Medknow Publications)

DOI

10.4103/0974-7796.127031

PMID

unavailable

Abstract

INTRODUCTION: "Primum non nocere" (first do no harm): Hippocrates (c. 460 BC-377 BC). Wrong site surgery is the fourth commonest sentinel event after patient suicide, operative and post-operative complications, and medication errors. Misinterpretation of the clinic letters or radiology reports is the commonest reason for the wrong site being marked before surgery.

MATERIALS AND METHODS: We analyzed 50 cases each of operations carried out on the kidney, ureter, and the testis. The side mentioned on clinic letters, the consent form, and radiology reports lists were also studied. The results were analyzed in detail to determine where the potential pitfalls were likely to arise.

RESULTS: A total of 803 clinic letters from 150 cases were reviewed. The side of disease was not documented in 8.71% and five patients had the wrong side mentioned in one of their clinic letters. In the radiology reports, the side was not mentioned in three cases and it was reported wrongly in two patients. No wrong side was ever consented for and no wrong side surgery was performed.

CONCLUSION: The side of surgery was not always indicated in clinic letter, theatre list, or the consent form despite the procedure being carried on a bilateral organ. As misinterpretation is a major cause of wrong side surgery, it is prudent that the side is mentioned every time in every clinic letter, consent form, and on the theatre list. The WHO surgical safety checklist has already been very effective in minimizing the wrong site surgery in the National Health Service.

Language: en

Keywords

Safety; human; male; patient safety; kidney disease; medical error; article; major clinical study; informed consent; patient care; priority journal; environmental factor; practice guideline; public health service; clinical protocol; world health organization; medical record review; radiology; testis disease; checklist; urology; kidney surgery; ureter disease; ureter surgery; male genital system surgery; universal protocol; WHO checklist; wrong site surgery