Wrong Patient, Wrong Surgery

Jackie (00:00):
When it says she never met the surgeon before going under, I don't understand that.

 

Dr. Chang (00:05):
Yeah.

 

Jackie (00:06):
She didn't sign a consent? She didn't speak to anyone?

 

Dr. Chang (00:13):
You are listening to Secret Services where we discuss the procedures nobody admits to, but everyone's curious about. I'm your host, Dr. Christopher Chang. Hi everyone. Back with another episode of Secret Services, our plastic surgery podcast at Congressional Plastic Surgery. I'm Dr. Chang.

 

Jackie (00:31):
And I'm Jackie.

 

Dr. Chang (00:32):
So today Jackie's going to tell us a little bit about a story, something that happened to her own mom at the hospital, which is kind of parallel with another viral story that went popular out of Australia earlier this week. But first we're going to talk a little bit about surgery and the processes that we do in surgery and in the hospital and things like that.

 

Jackie (00:53):
Right. So when we're prepping someone for surgery, what do we do to make sure that we have the right person, the right surgery, right side?

 

Dr. Chang (01:05):
Right. So that's a very common part of doing surgery is the patient identification, the procedure identification, and we have a lot of protocols. I think in surgery particularly, we are often focused on preventing errors. And there's a huge movement over the past, I don't know, 20 or 30 years of creating processes that are very regulated, repeatable and systematic that you don't make those kind of silly mistakes. So they always check the patient armband, date of birth, identification. You make sure if you're doing, let's say a right knee replacement, that you've marked the right knee with your initials and then the patient's initials. And the consent form has to say right knee. If you have implants, that you have a right knee implant.

 

Jackie (01:52):
Yes.

 

Dr. Chang (01:53):
And some surgeons even go so far to test every piece of equipment to make sure the power's on, that you have the right tools and that kind of thing.

 

Jackie (02:00):
Right. And so what we do before surgery is called a timeout or a surgical pause. Supposed to be done in every surgery across the world to prevent these things. We oftentimes have a form that we all fill out, sign saying that we did it. And yeah, so basically what you're supposed to do is the patient's prepped and drape. You're supposed to stop everything, no talking, no music. Whoever's leading the timeout. I've worked places where the surgeon had to lead the timeout. Other places it's the nurse.

 

Dr. Chang (02:32):
Did you ever work in a place where you had to identify? Everybody in the room had to say who they are?

 

Jackie (02:36):
Yes. We had to go around and introduce ourselves so that they would say it would make it so you know everyone in the room and if anything was going wrong, you would know how to approach them by name to speak up basically.

 

Dr. Chang (02:49):
Right. The intention for that is so that everybody knows everybody else and it's not -

 

Jackie (02:54):
Yeah. You would state your name, your role.

 

Dr. Chang (02:57):
It's not intimidating to sort of speak up if there's a problem.

 

Jackie (02:59):
You would say the patient's name, date of birth. The anesthesia provider who's kind of under the drapes is supposed to be checking that against the armband on the patient to make sure you have the right patient. You're supposed to read the exact consent that the patient signed with the procedure, who's doing it, the laterality. It even goes so far as if you're doing right breast, you're not even supposed to just write an R. You have to write the word right out. You're supposed to check the implants in the room at this time.

 

Dr. Chang (03:32):
Have you ever done that where you did a timeout and the surgeon said one thing and you're like, "No, no, no, it's the left side or whatever." And you'd say, "Now we got to stop." Or what do we do? Do we wake the patient up?

 

Jackie (03:45):
I have not while the patient is asleep, but I have left. I've gotten my room set up. I've gone to the pre-op area where you kind of do your initial introduction to the patient. You check the consent, kind of confirm everything we're doing. There's been a time where we've set the room up for a right knee and then I go and look at the consent form and they wrote left knee. So then you have to stop everything there and be like, What is the truth? Did the posting person who gave us the schedule in the back just put the wrong thing, but the surgeon, the patient, they all know the right side. We were just misinformed in the back.

 

Dr. Chang (04:25):
And they have a name for that kind of thing at a hospital called near misses.

 

Jackie (04:28):
Yes.

 

Dr. Chang (04:28):
And I think it's an award when you catch a near miss or not. I don't know. Sometimes it's a celebrated thing, I guess.

 

Jackie (04:35):
Every near miss is supposed to be documented as an incident report. And then it's reviewed by either the medical director and a committee that they have, and they just kind of look at it to evaluate the process, like what went wrong here? How did this happen? And then yeah, they would usually give you a little shout at a huddle like, "Hey, you stopped this problem from happening." I've been in a situation where the wrong implants were in the room. Luckily it was at a large hospital where they have a closet down the hallway where they can just go pull all the right stuff. But again, not all places have that luxury.

 

Dr. Chang (05:14):
Generally in plastic surgery, I think that we don't run into that problem too much, right?

 

Jackie (05:20):
It's definitely way worse for orthopedics or spine, big cases with a lot of hardware. Especially a lot of the hardware, it could only go on the right side.

 

Dr. Chang (05:34):
And it's expensive. I mean, these are extremely thousands and tens of thousands of dollars of specialized medical equipment.

 

Jackie (05:41):
But for us, if we're like, okay, we need a size 300 implant, that could go in either breast. But these orthopedic ones, it's like, if you don't have the right side, you're -

 

Dr. Chang (05:50):
And you're generally not going to put it just in one breast unless you're doing reconstruction. And if that's the case, then they already have their natural breast on one side. So you're not really going to make a mistake where they have had a mastectomy and they have a flat chest. So everything in plastic surgery generally is about symmetry or balance from the left side to the right side or in the midline. And so that prevents that issue from being too common, I think.

 

Jackie (06:15):
Well, it's one of those things too. It's very, very highly regulated with all the joint commission, quad A. It's a big thing. So when you hear these stories of it actually happening, like wrong site surgery, stuff like that, you're always just like, how?

 

Dr. Chang (06:33):
Yeah. How did you get through all of those safety checks and still this happened?

 

Jackie (06:38):
But there are certain personalities out there where, as hard as you want to try to enforce the timeout, some doctors, they're like, "I don't have time for this. I don't want to do it." And so I think as a nurse, that was a big struggle in the bigger hospitals was literally just getting the surgeon to do the timeout half the time.

 

Dr. Chang (06:57):
Yeah. I mean, a lot of surgeons, especially who are busy or who are a bit gruff or hard to approach, if they are pushing back and they just want to rush, they're like, "Oh, it's never happened to me", until it does.

 

Jackie (07:11):
And I would say it would usually be the very experienced surgeons. They've been doing it for years. I don't need to do this.

 

Dr. Chang (07:18):
It's never happened.

 

Jackie (07:19):
Yeah.

 

Dr. Chang (07:19):
Right.

 

Jackie (07:20):
And when you get a little cocky, that's when stuff gets bad. So this segment, this person said, "I'm scheduled for a rhinoplasty next month, and I'm honestly more scared about something going wrong administratively than about the surgery itself. What can I actually do to protect myself before I go under? What do people not know to ask?"

 

Dr. Chang (07:39):
Before you go back, as the surgeon is getting your consent, that's when you're going to really be able to emphasize or discuss the details. If it's a big picture thing like, "Oh, well, are we replacing both breast implants? Or are you going to bring down the hump?" But if you say, "In the case of a rhinoplasty, well, I'd really like to have a very subtle slope instead of a straight profile. So do everything you can to kind of..." Those fine sort of stylistic nuances that you want to emphasize are best done right when that is fresh before the surgery, when you just want to express those are the three most important things I want to make sure I get out of this.

 

Jackie (08:20):
I would also say, well, one, for rhinoplasty, there's one surgical site. It's not like you have two noses. So that eliminates some risk. I also think you see a lot of the more administrative issues in emergent situations versus elective planned procedures because that's when you're kind of racing against the clock and that's when the computer or writing a consent. Sometimes in emergent situations, there is no consent. In traumas, there isn't one. So I feel like those situations, you're more inclined to have a hiccup in the system.

 

Dr. Chang (09:01):
Right. When you rush essentially and you're bypassing, you're trying to do the best for the patient, but you're bypassing a lot of the procedures. But yeah, I think that that's when patients, they should feel empowered to speak up, but really organizing your thoughts is really the most important thing. If you come with a laundry list of things, it's just a little bit overwhelming for everybody, for you, for the patient, for the surgeon, for the nursing. Focus on what's really, really your top concerns. Because overall, in the consultation and all the other processes, that's kind of where you get into every little nitty gritty. But when it comes down to game time, we got to be focused on those details.

 

Jackie (09:39):
And all the staff in the room needs to feel comfortable to speak up. And that also is another thing where it's like, that's when it's great when you work with the same people often. You guys work together every day. You're like, "If I see something that I don't think is right, I can speak up and say it and not feel like you're going to tear me down or not respect my opinion." So I do think that is a hurdle for younger nurses, younger people in healthcare to get over. And I think it just comes with time and just confidence in yourself to be like, "All right, I know that I know what is right and wrong. I'm going to speak up."

 

Dr. Chang (10:17):
That's what I think is great about our center is having very experienced, very qualified people, but also being very comfortable with the types of surgeries we do. Lots of experience of outpatient, healthy patient surgery, as well as familiarity with each other as the team and everybody has the same role. It's like you have Tom Brady throwing passes to Rob Gronkowski. He's thrown thousands of passes. He just knows where he's going to be on the field and they know how to work together. And if something doesn't go right, they work it out. They don't just say, "Well, I'm breaking my contract, go to a different team next year," kind of a thing. So those are important parts of being part of the team. The surgical process is many layers involved and also many people that are there for your safety and make sure the surgery goes smoothly. So now it's your turn. You got to tell us. So Jackie, what happened to your mom?

 

Jackie (11:10):
This is a crazy story. So one of the things that I notice a lot when I am introducing myself to patients in pre-op, you always do, it's grilled into your brain. It's like, "Hi, I'm Nurse Jackie. Tell me your name and date of birth." And they tell you verbally and then you look at their armband and you make sure that it is correct. And everyone is supposed to do that when they come in and out of the room. And I often have patients who get annoyed. They'll just say a fake name because they're like, "Well, I've already been asked this a hundred times." And I'm like, "It's for safety." But they get annoyed. So my mom, she had a heart attack and she had to have a cardiac cath placed. So by the time I got to her, she was already in the ICU. And so -

 

Dr. Chang (12:01):
Oh, so it was pretty -

 

Jackie (12:01):
It was emergent. 911, straight to cath lab. So emergency situation where things can go south. I get to the ICU, they have a handwritten board, and I noticed that our last name is spelled incorrectly, but I'm like, "Okay." The person writing the board, O'Brien, A-E, it could go either way. But I was like, "That's weird." So I go in and I'm talking to her. And so then I just look at her armband because I'm like, "Oh, I wonder if they spelled our last name wrong on the armband." And I see that her first name is spelled differently. The last name is spelled differently. Same name, spelled differently, different birthdate. So basically whoever was doing the intake in the ED just typed her name and I'm sure they just got a list. So they came out. Yeah. So it was like someone who's been seen in that hospital system before, just clicked it, did everything.

 

(12:56):
They admitted her to the ICU under the wrong name. They put an implant in her under the wrong name. All of her -

 

Dr. Chang (13:05):
They did the right surgery.

 

Jackie (13:06):
They did the right surgery.

 

Dr. Chang (13:09):
They got the correct vessel to stent.

 

Jackie (13:10):
They got the right vessel. But then, so I immediately bring it up to her nurse and it turns into this whole cluster basically, because they had to go change all the records, modify everything. And then now whoever that other lady with the same name, if someone looked at her chart, it would look like, oh, well you -

 

Dr. Chang (13:29):
She had a stay, ICU stay.

 

Jackie (13:30):
Yeah. So it takes a while. They fix everything. And then she gets discharged and they're like, "You immediately need to make an appointment with this cardiologist." The cardiology office is like, "Well, we're trying to get you in here, but we can't find any of your records from the hospital." Because they were in the middle of merging the charts. So it's basically delaying her care to get seen by a cardiologist, to get put on all of these maintenance drugs for her MI. And it was crazy.

 

Dr. Chang (14:05):
Well, you think about this, the cardiologist was probably called as a consult. Come see this patient who had a fresh MI, a fresh stent. And then he's communicating with his office, says, "Tricia O'Brien is this patient I saw in the hospital. Let's put her in this system so when she calls her follow up, we'll make her an appointment in two weeks or whatever." And then they're like, "No, you're not in our system," because they're going with the original lady's name.

 

Jackie (14:28):
Yeah. Yeah. We can't find anything. So because of that, we're going to have to put you on the regular list to get into the cardiologist. And it's like, no. So it was a lot of back and forth. I wrote a letter to the hospital because I was just like, "This is crazy." And I know errors happen, but more importantly, I just want it to be addressed and everyone in the situation aware because again, they did the right surgery, she survived, everything was fine. She was happy and healthy. But those are things you don't even think, how could this affect me later on down the road? And it did. So now when I have my patients get an attitude or give me a fake name, I'm like, "Hey, this is actually very important."

 

Dr. Chang (15:12):
Yeah. I mean, it's very hard to unwind the medical record.

 

Jackie (15:17):
Yes.

 

Dr. Chang (15:17):
And that is a huge thing. And I don't know if we've talked about this before with allergies, but once you have an allergy listed in your medical record, let's say it's a wrong allergy, it is very hard because they will not give you the medicine in that class.

 

Jackie (15:30):
Even if you are the provider yourself and you're like, "I accidentally checked that box." It's still just like -

 

Dr. Chang (15:35):
It's like an act of God

 

Jackie (15:37):
To change it.

 

Dr. Chang (15:37):
To take that off because they don't want to hurt anybody. I get it. It's very, very difficult. But if you don't really have a penicillin allergy and you're marked that way, it eliminates a huge amount of therapy for you. So instead of having all of these choices for antibiotics, you now have a much smaller roster to choose from. And that really could be limiting. The other options could be more dangerous to your kidneys or it could have other side effects or it could be more expensive for the overall health or your insurance might not cover it. It's just like we have to be able to be able to recognize a mistake and fix the mistake just as -

 

Jackie (16:12):
Well, and then you kind of just have to rely on the system because it's like, okay, so they fixed it, but you got to wonder, did they take everything out of that other lady's record? Or in a few years is she going to go in and they're going to be like, "Well, why were you seen this day?" Who knows?

 

Dr. Chang (16:27):
Yeah, yeah, yeah. The poor lady's going to have a lot of questions. She's not going to -

 

Jackie (16:31):
Did she get bills? I mean she may have because they already started the process of all of that. We put that stent in, here you go. They're already working on it.

 

Dr. Chang (16:43):
Yeah, exactly. Yeah, exactly. She got an EOB and her insurance was already billed and she's going to own a deductible and a copay for an ICU stay.

 

Jackie (16:50):
And this lady has no idea that this is going on.

 

Dr. Chang (16:52):
Yeah, that could be bad. That's a good point.

 

Jackie (16:54):
Yeah. It was truly shocking to me, but I was like, wow, I'm even in it. And luckily I caught it. But yeah, say my mom's daughter wasn't a nurse, it would've just gone on. My mom would've never looked at her armband to be like, "Is that me?"

 

Dr. Chang (17:11):
Or been like, "Ah, they misspelled it. Who cares? They knew who I am." It's interesting because in Australia where this story's going to come from, I think they have a public and a private healthcare system. So I don't know if whether that'd be interesting if you were seen in one and it wasn't covered or the government had to cover it or whatever if it went to the wrong person. But this lady's from Melbourne. So Deborah Buchanan, the Melbourne grunt mother went to Sunshine Hospital. Sounds like a nice hospital.

 

Jackie (17:38):
I know. I like that name.

 

Dr. Chang (17:39):
In January, earlier this year to have a small cancer skin tag removed. She woke up to find surgeons had removed a large portion of her external genitalia instead. Staff confused her with another patient named Deborah. And when called, Buchanan asked if they meant Buchanan and they said, "You'll do."

 

Jackie (17:59):
God.

 

Dr. Chang (18:00):
She never met the surgeon before going under. She woke up hemorrhaging. Her cancer was still untreated and had to return to the same hospital for her original procedure. And so she's now suing. This is crazy. So I have lots of questions. Deborah says staff told her that you'll do when she questioned whether they had the right patient. So I don't know. Have you ever heard anybody say you'll do? I guess you're the one.

 

Jackie (18:24):
Okay. When I hear that, I'm like, did they think they were joking with each other like, "Oh, Buchanan. Yeah, you'll do." I don't know.

 

Dr. Chang (18:35):
Right.

 

Jackie (18:36):
That lady's -

 

Dr. Chang (18:37):
This is her interpretation.

 

Jackie (18:38):
Correct. Yeah.

 

Dr. Chang (18:39):
So this is her telling the story because she's suing. So she's saying -

 

Jackie (18:42):
Did they really say that? Or did they think this lady's just joking around? I don't know. Because if she just said, "Do you mean Buchanan? I don't know."

 

Dr. Chang (18:52):
Imagine if you're in the waiting room and say, "Deborah, is Deborah here?" And then she goes, "Deborah, Buchanan." You like, "Yeah, you'll do." Kind of joking. I could see somebody doing that. You know what I mean?

 

Jackie (19:02):
Yeah.

 

Dr. Chang (19:03):
Maybe inappropriately, but it's not that far-fetched.

 

Jackie (19:07):
I just personally would not. I mean, it's a little different in the Congressional Plastic Surgery clinic waiting room to call someone by their first name. But I don't know. In surgery, if I was going out to the waiting room, I would say their last name. I would not be like, "Oh, where's Deborah?"

 

Dr. Chang (19:24):
Yeah, it's not that.

 

Jackie (19:25):
I would say Buchanan.

 

Dr. Chang (19:26):
Especially at Sunshine Hospital.

 

Jackie (19:28):
Yeah, exactly.

 

Dr. Chang (19:28):
You got to call them Mrs. Buchanan.

 

Jackie (19:30):
Exactly.

 

Dr. Chang (19:32):
But I have a bigger question about you're supposed to remove a skin tag and you end up removing this woman's external genital. First of all, I thought male genitalia was generally external genitalia, but.

 

Jackie (19:44):
And this is where the story I'm just like -

 

Dr. Chang (19:45):
She had a labiaplasty? What happened?

 

Jackie (19:47):
I don't know what that means. I guess. Or maybe it was maybe a lesion on the genitalia.

 

Dr. Chang (19:54):
I guess they are plastic surgeries. I mean, some sort of a skin tag or skin cancer removal. I could see that. Unless it was a skin tag on her genitalia.

 

Jackie (20:03):
No, I don't think so. Because I think she was confused. "Why am I hurting and bleeding down there when that's not where my skin tag is?"

 

Dr. Chang (20:17):
Oh, interesting. Yeah.

 

Jackie (20:18):
I mean - Yeah, maybe the genitalia, maybe someone else had a lesion on their - On their labia that was getting removed.

 

Dr. Chang (20:25):
Well, the other thing that's weird. And in that instance, you don't really mark the genitalia, but at least in the pre-op area. Maybe make an arrow and point down.

 

Jackie (20:37):
Some do. Some do.

 

Dr. Chang (20:37):
Oh, they do? I know exactly what you're referring to.

 

Jackie (20:41):
Yes.

 

Dr. Chang (20:41):
Not me.

 

Jackie (20:42):
Not you.

 

Dr. Chang (20:43):
Yes. But you can draw an arrow or something and mark. But the thing that prevents that from happening usually is the way the room is set up before you go back, the room is set up with certain instruments and certain things depending on the anatomic area you're going to operate on.

 

Jackie (20:57):
Right. Correct. So I think probably everyone in that room, that whole surgical team, they were thinking genitalia. But my questions are, okay, when it says she never met the surgeon before going under, I don't understand that. Yeah. She didn't sign a consent. She didn't speak to anyone?

 

Dr. Chang (21:20):
Yeah, that's also bizarre.

 

Jackie (21:21):
But again, I don't know how they do it down under, but -

 

Dr. Chang (21:23):
Yeah, she went down under.

 

Jackie (21:25):
Because I was like, as a patient, as a way to be an advocate in the pre-op area when you're signing consent, make sure you're reading everything that you sign. So in that moment, she could have been like, "Well, what about my skin tag?"

 

Dr. Chang (21:39):
PSA, if you are going for surgery of any kind, make sure you meet the surgeon beforehand. Even in the trauma situation, the surgeon should be seeing you or your family member. Sort of explain what they're going to do. They got to get consent permission or at least tell you. So I think that's a huge red flag. And if you don't meet the surgeon, that is a real problem. You should be, "Hold on. Who is doing this operation?"

 

Jackie (22:06):
Yeah, exactly. And so they said the hospital said staffing shortages were a factor.

 

Dr. Chang (22:12):
Yeah. I think that's just a crazy response or comment. I wouldn't even put that comment out there. Even if that were true, I just would not put that comment out there. Let that go to the investigation or the litigation or whatever the settlement that they're going to discuss because that's just a stupid thing to say for blame for this.

 

Jackie (22:31):
So I don't even know how you could twist that as a justification for this.

 

Dr. Chang (22:39):
Probably they go to their legal department and they say no comment, essentially. I think that there's not an easy way from a system standpoint until they do their own investigation and figure out what's going to happen there. But since it's a lawsuit, you got to follow whatever the legal or ethical piece.

 

Jackie (22:54):
That's basically what the hospital said. They were like, "We can't comment on individual patients." But I would be interested to see the internal investigation because clearly it's deeper. There were a million, what do they call that? The Swiss cheese model. Yeah.

 

Dr. Chang (23:11):
For a mistake like that to me, there has to be multiple places -

 

Jackie (23:15):
Multiple errors.

 

Dr. Chang (23:16):
Where the errors or somebody overlooked this or that. There's just too many processes and too many people involved, even if you had a staffing shortage for that to be happening. So as you said, Swiss cheese model.

 

Jackie (23:29):
Yeah. When a patient asks, "Are you sure you have the right person?" And the answer is, "You'll do," what does that tell us about the culture inside the operating room or hospital?

 

Dr. Chang (23:39):
Yeah, I think this is a comment about a hospital or the essentially registration area. It's just too casual.

 

Jackie (23:47):
Yeah.

 

Dr. Chang (23:47):
It's too cavalier. It's just, I think, a culture that this is a pretty serious thing. Even if we're low stress, having fun, happy surgery, not a heart attack, there are some things you just don't want to be too cavalier about.

 

Jackie (24:03):
Right. You can't start cutting corners or being a little lax on the basics because then this will happen. But she says she wants to go back to the same hospital for the correct procedure.

 

Dr. Chang (24:16):
Yeah. Well, we'll have to dig into Deborah a little bit and see.

 

Jackie (24:21):
Yeah, we got to follow up. We have to follow up with Deb at Sunshine Hospital.

 

Dr. Chang (24:25):
Everybody. Yeah. So hang tight. We'll see what Sunshine Hospital has left and how it all turns out.

 

Jackie (24:31):
Let us know your thoughts about the wrong site operation and if you've ever heard of any other experiences like that.

 

Dr. Chang (24:39):
Yeah. If that's ever affected you, let us know in the comments below. Talk to you soon.

 

Jackie (24:43):
Bye.

 

Dr. Chang (24:45):
Thanks for listening to Secret Services, the podcast where we see everything and say nothing except right here. I'm Dr. Christopher Chang, double board certified plastic surgeon located in Tysons, Virginia. Follow us on TikTok @congressionalpsurgery or on Instagram @congressionalplasticsurgery. To send us a classified message or to hear more episodes, go to secretservicespodcast.com. Links to everything we talked about on today's show are available in the show notes. Oops, patient's here. We got to go.