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.”