Doctor Operates On Wrong Leg

Surgeons at Yale-New Haven Hospital are under close monitoring for three months after the victim of a motor-vehicle accident suffered a surgery to the wrong leg.

The hospital reported the June 9 screw-up to the state Department of Public Health (DPH), which conducted an investigation and concluded doctors should have taken a “timeout” before the surgery. The hospital is now undergoing a corrective plan, with surgeries monitored for a three-month period ending Dec. 1.

Here’s what happened, according to a one-page DPH report:

An unnamed patient was admitted to the hospital on June 9 after a motor-vehicle crash. The patient suffered fractures to the right ankle, pelvis and “nasal structure.” The patient was brought to the operating room to repair the right ankle. While transferring the patient to the operating table, a doctor, described only as Chief Surgical Resident #1, noticed the patient’s left leg was “internally rotated and shorter than the right leg.”

The resident discussed the discovery with Attending Physician #28 and came up with an additional intervention: After fixing the right ankle, they would place a pin, called a skeletal traction, into the left leg.

The plan went awry when the first resident handed off the reins to a second resident (“Chief Surgical Resident #2”) after completing the ankle surgery. Resident #2 then “placed the skeletal traction onto the right leg instead of the left leg.”

The second resident “discovered the error when he was writing postoperative orders” and reviewing the diagnoses. The resident then “removed the traction pin from the right leg and placed a new one in the left leg.”

The hospital reported the incident to the state, which started a probe into what went wrong. It was determined that the residents failed to perform a “surgical timeout.”

A “timeout” is “a pause by the surgical team to review the procedure before it begins,” giving everyone on the team the chance “to raise a concern or offer comment,” said hospital spokesman Vin Petrini.

Timeouts are required by the hospital’s Universal Protocol, a standard policy designed to prevent surgeries to the wrong site or wrong person.

The hospital’s protocol states that when a second doctor is required to perform an extra procedure, and the attending surgeon is not present during the initial timeout when the surgery was discussed, the doctor must hold a second timeout to discuss the plans.

An official from DPH interviewed Resident #1 and #2 and determined that “there was no time out and no communication between the residents as to what leg needed the traction.”

The incident constituted a violation of state regulations, according to the DPH report.

As a result, DPH laid out a “plan of correction” for the hospital.

On Aug. 9, the hospital’s Universal Protocol for Surgery/Invasive Procedure was updated to call for a second “timeout” anytime an extra procedure is added to a patient’s intervention, regardless of whether there is a change in the surgery team. The policy changes were communicated to relevant staff on Aug. 23.

On Sept. 1, the hospital began a three-month audit to make sure that these second “timeouts” are documented. The audit is being overseen by the hospital’s medical director and nursing director of perioperative services.

Yale New-Haven’s Petrini issued the following statement in response to the incident:

“When caring for patients with multiple and complex trauma, we understand that outcomes reflect a number of factors, including the performance of health care providers and the nature of the injuries suffered by the patient. While we are grateful that the patient involved was not seriously or permanently harmed, we take our commitment to providing high quality care and our reporting responsibility to the State Department of Public Health very seriously. As a result, we reported this incident to the State in a timely fashion and have taken appropriate steps to diminish the likelihood of a recurrence.

“As the State’s busiest Level 1 trauma center, we focus on ensuring that universal protocols, including surgical time-outs, are consistently met. 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.”

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posted by: Joanne Sciulli on November 2, 2010  1:33pm

I don’t think the patient should sue in this case.  Why?  Because he hasn’t got a leg to stand on.

posted by: M on November 2, 2010  4:06pm

Too soon Joanne, too soon.

posted by: Fairhaven Dave on November 2, 2010  5:13pm

Ha ha ha!!!! HA HA HA HA!!! “Plan of Correction…”  HA HA HA!!!!  Good idea! 

“You guys talk funny.  SAY MORE WORDS!”  -Patrick Star

posted by: Concerned Citizen on November 3, 2010  9:33am

There is nothing to laugh about here.  This is a mild error compared to some of what they do.  These types of “accidents” happen far more frequently and have far more dire consequences than are stated here, or are reported.  Quite often there are important notes in patients’ charts that are not read by the surgeon or consulting physicians who perform procedures that maim or have serious permanent effects on people’s lives.

When patients or relatives complain about mishaps they are then labelled; the charts are flagged that these people are difficult, or trouble-makers, so everyone avoids them, or give them cryptic or partial answers to important questions.  Hospitals are often not friendly places for patients.  For example, they never under bill you, but they often over bill for service that has not been provided.

The ER at Yale is often a nightmare experience with the highest price tag.  Ask them for a breakdown of your $3,700 bill for a day in the ER and you get put into a collection agency! Hospitals are places where major cover-ups take place. Establishing a positive relationship with a few of the nurses is often the best way to get good care and protection.

People need to learn how to navigate the hospital terrain; this is especially true for large facilities such as Yale.  The arrogance and the hierarchy there account for some of the errors; they cover up much more than is revealed. Patients sometime accept payments for their silence not realizing that will only compound the problems in the long run.

Thanks to the NHI for telling us about this.  Health Care Literacy is an important topic.

posted by: Joanne Sorry on November 3, 2010  10:13am

I’m so sorry. Coming from a family that dealt with an amputation due to a motorcycle accident with humor, I couldn’t resist sharing one of the stupid jokes.

posted by: Fairhaven Dave on November 3, 2010  10:52am

NOT sorry.  Doctors are humans, not Gods.  They are as likely to screw up as the kid making your breakfast sandwich.  If they were perfect nobody would be nervous before surgery and healthcare would be affordable because there would be no lawsuits.

“Plan of Correction”  HA HA HA HA!!!....  18 hours later and still funny.

“That’s Doctor PROFESSOR Patrick to YOU!” - Patrick Star

posted by: Brian Casey on November 3, 2010  7:33pm

I had surgery in June at Yale New Haven. The surgery went fine. The residents that were supposed to care of me,told me me the morning after the surgery, that my lungs were filling with fluid. They said they would be right back, and vanished for nine hours. the nurse would not intervene with the residents. I had to demand a trauma team, that nurse saved my life. The residents are poorly supervised children. I requested my records, they were cleaned. I have received much care at Yale new Haven, in the past two years, the residents are poorly supervised.
  Brian Casey, New Haven