A
patient who was hospitalized in a dedicated Trauma Centre run by the Delhi
government with head and face injuries that he sustained in an accident,
instead underwent surgery under GA for a fractured leg, as reported in TOI. The
surgeon mistook him for another patient admitted in the same ward who had a leg
fracture. A small hole was drilled into the patient’s right leg to put a pin on
Thursday morning. As the procedure had been done under general anesthesia, the
patient could not realize or object to it. However, the pin was removed within
hours following a corrective surgery after it was brought to the attention of
the authoritis. A committee examined the case found merit in the allegations
and a disciplinary action was initiated against the doctor, a senior resident,
who has been barred from conducting surgeries without supervision with
immediate effect.
Res
ipsa loquitur is a Latin term, which literally translates as “the thing speaks
for itself”. The doctrine of res ipsa loquitur is a rule of evidence in cases
of medical negligence. It infers negligence from the very nature of an accident
or injury in the absence of direct evidence on how any defendant behaved. Res
ipsa loquitur is not applicable when determining the liability for criminal
negligence; it applies only in cases of civil negligence.
To
prove medical negligence, usually three components have to be established:
- There was an
element of duty to be performed
- There was breach of
duty
- Resultant damage
If the
patient is not harmed by the physician’s error, then the patient cannot recover
damages arising out of the error.
This
case answers ‘yes’ to all the three components of medical negligence: there was
a duty of care, there was a breach in the duty of care and the patient did
suffer damage as a direct result of the breach.
In res
ipsa loquitur, these three components of medical negligence elements are
inferred from an injury that does not ordinarily occur without negligence i.e.
negligence is evident and the complainant does not have to prove anything as
the “thing proves itself” as also in this case.
This
is a medical error and can be classified as a ‘never event’ i.e. event that
should never occur under any circumstance. Never events are defined as adverse
events that are serious, largely preventable, and of concern to both the public
and health care providers for the purpose of public accountability. They are
usually a direct result of a negligent action and no trial of expert’s evidence
is necessary
The
US National Quality Forum has defined 29 never events segregated
into seven categories: surgical, product or device, patient protection, care
management, environmental, radiologic, and criminal.
“Surgery
or other invasive procedure performed on the wrong patient” is included in list
of surgical never events along with “surgery or other invasive procedure
performed on the wrong body part, wrong surgical or other invasive procedure
performed on a patient, unintended retention of a foreign object in a patient
after surgery or other procedure”.
The
World Health Organization (WHO) has developed a Surgical Safety Checklist, to
be read out loud, to decrease errors and adverse events for use in any
operating theatre environment. The checklist has three phases as below:
“Sign
In”: Before induction of anesthesia
- Has the patient
confirmed his/her identity, site, procedure and consent?
- Is the surgical
site marked?
- Is the anaesthesia
machine and medication check complete?
- Does the patient
have a: Known allergy, Difficult airway/aspiration risk or Risk of
>500ml blood loss (7ml/kg in children)?
“Time
Out”: Before start of surgical intervention
- Have all team
members introduced themselves by name and role?
- Surgeon,
Anesthetist and Registered Practitioner verbally confirm: What is the
patient’s name? What procedure, site and position are planned?
- Anticipated
critical events (surgeon, nurse, anesthetist)
- Has the surgical
site infection (SSI) bundle been undertaken? Antibiotic prophylaxis within
the last 60 minutes • Patient warming • Hair removal • Glycemic control
- Has VTE prophylaxis
been undertaken?
- Is essential
imaging displayed?
“Sign
Out”: Before any member of the team leaves the OR
- Registered
Practitioner verbally confirms with the team:
o Has the name of the procedure
been recorded?
o Has it been confirmed that
instruments, swabs and sharps counts are complete (or not applicable)?
o Have the specimens been
labelled (including patient name)?
o Have any equipment problems
been identified that need to be addressed?
- Surgeon,
Anesthetist and Registered Practitioner: What are the key concerns for
recovery and management of this patient?
However,
when deciding the quantum of punishment, the mitigating circumstances need to
be considered.
Does
the hospital have a protocol in place to avoid such mistakes? Generally, a
minimum of two ID marks are required to be checked at the time of surgery. More
than one patient can have the same name; room numbers may not be reliable as an
identification mark. Matching of HUID no. is important.
Being
overworked, lack of resources and infrastructure, insufficient staff etc. is no
excuse for not following such a checklist.
There
should be guidelines and/or protocols in place, which should be strictly
implemented. If there are no guidelines, then there is an urgent need to
develop them as per requirements. The checklist must be completed for each
patient who undergoes a surgery, including under LA. It also must be documented
in the patient chart.
By
following these few but crucial steps, such errors can be minimized. It also
ensures effective team work.
This
mistake is not just that of the doctor alone. It is also a result of system failure
and administration error.
Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart
Care Foundation of India
Immediate Past
National President IMA
