What to do if a patient undergoes wrong-sided below knee amputation due to a mix-up with another patient of the same name?

Management of Wrong-Site Surgery: Immediate Incident Reporting is Essential

In the case of a wrong-site below knee amputation due to patient identification error, writing an incident report is the most appropriate immediate action to take. 1

Understanding the Error and Immediate Response

When a wrong-site surgery occurs, such as amputating the incorrect limb, this represents a serious sentinel event that requires immediate documentation and reporting through formal channels. The error occurred due to:

1. Two patients with the same name being admitted for below knee amputations (different sides)
2. One patient leaving against medical advice
3. Incorrect patient identification and handover between ward and operating room
4. Failure of surgical site verification protocols

Proper Response Protocol

Immediate Actions:

• Inform the patient and family about the error honestly and transparently 1
• Document the error in the medical record
• Write an incident report to document the sentinel event 1, 2
• Notify hospital administration and risk management
• Arrange appropriate care for the patient, including consultation for management of bilateral amputations

Why Incident Reporting is Critical:

• Allows systematic analysis of the error and contributing factors 3
• Facilitates learning from the adverse event to prevent recurrence 4
• Fulfills legal and ethical obligations for transparency 1
• Enables appropriate institutional response and process improvement 2

Avoiding Inappropriate Responses:

• Do not write only a case report to the director (insufficient formal documentation)
• Do not fight or harm the ward sister (unprofessional, unethical conduct)
• Do not only complain against the OR nurse (focuses blame rather than addressing system failures)

Systemic Approach to Prevention

This error represents a system failure requiring multiple interventions:

1. Patient Identification Protocols:

   • Implement universal protocol for surgical site verification
   • Use multiple identifiers beyond patient name
   • Perform "time out" verification before anesthesia and incision

2. Communication Procedures:

   • Standardize handover processes between units
   • Document DAMA/absconded patients clearly in electronic systems
   • Implement surgical safety checklists with verification steps

3. Cultural Changes:

   • Foster a culture of safety and collective learning rather than blame 1
   • Encourage transparent error reporting without fear of punishment 3
   • Establish clear protocols for managing sentinel events

Long-term Follow-up

After incident reporting, a thorough root cause analysis should be conducted to identify all contributing factors and implement system-wide changes to prevent similar errors in the future. This should include review of patient identification protocols, surgical site marking procedures, and communication processes between departments.

Remember that medical errors often result from multiple systemic factors rather than a single cause 1. The focus should be on improving processes rather than assigning individual blame, while still maintaining accountability for patient safety.