Wrong Knee Operated On In California Hospital

When a patient enters a hospital for left knee surgery and wakes up to find out that his right knee has been operated on in error, he is not a happy camper. Neither are officials of the State of California Department of Public Health who recently investigated the error.

The wrong site operation occurred in Orange County, California, at St. Jos ph Hospital. According to media reports, this is the third incorrect procedure that has been performed at the hospital since January 2006. The others both involved wrong side of the body operations – one to the head and another involving the ears.

Here is what happened according to the documented investigation by the California Health and Human Services Agency. It reveals an interesting mix of communication and miscommunication, both verbal and written, on the way to surgery on the wrong knee. In a preoperative interview, Nurse A discovered that the surgery schedule for the patient noted that surgery was to be done on the right knee. In that interview the patient made the correction in stating it was to be left knee surgery. At this point the nurse alerted a nurse at the surgery desk, the anesthesiologist and the surgeon about the correction. The word “right” was crossed out on the surgery schedule and the word “left” written in.

It was also noted that a consent form from the patient noted left knee surgery. The patient was then taken to the operating room. Here, an operating room technician noted that no markings for surgery appeared on the right leg. However, the surgery procedure board in the operating room listed the surgery to be performed as right leg.

In the operating room, Nurse C said that she had spoken to the patient in the preoperative area and saw that the left knee was marked when he entered the surgical area. However, when she worked to prepare the patient for surgery, she set up the right leg to be operated upon and wrote “right knee” on the procedure board.

However, as she continued to prep the patient for surgery, she noted the absence of markings on the right knee and that no surgical preps had been done on that knee. A “time out” was done prior to the surgery. The surgeon read the consent form out loud as right knee. Two patient identifiers were used to identify the patient. However, no procedural verification was done with the patient at this time to verify which knee was to be operated upon. At this point the operation proceeded on the wrong leg.

The error was discovered when the patient woke up in the recovery room and became aware that the surgery  had been done to the wrong side of his body. An unfortunate and now common place error.

Source: The California Health and Human Services Agency, Department of Public Health. “Statement of Deficiencies

and Plan of Correction.” March 2008.

http://ww2.cdph.ca.gov/certlic/facilities/Documents/HospitalAdministrativePenalties-2567Forms-