From the Guidelines
The defect in this scenario is a booking defect. This error occurred because there was a change in the surgical schedule (cancellation of the bilateral implant case) and the unilateral left-side implant patient was moved up without proper communication to the surgeon. The fundamental issue is not with the marking process itself, but with the failure of the scheduling system to accurately communicate which patient was on the operating table. In a proper booking system, the surgeon would have been informed about the schedule change and would have reviewed the correct patient's information before beginning the procedure. While marking is important to prevent wrong-site surgery, in this case the primary breakdown occurred earlier in the process when the schedule was changed without proper notification, leading to confusion about which patient was being operated on rather than which side of the same patient needed surgery. As suggested by experts in critical situations, the use of closed-loop communication can reduce morbi-mortality and limit the incidence of adverse events 1. In this scenario, the lack of proper communication between the scheduling team and the surgeon led to the mistake, highlighting the importance of effective communication in preventing such errors. Additionally, guidelines on consent for anaesthesia emphasize the importance of providing patients with sufficient information and time to make informed decisions, and the duty of the anaesthetist to ensure that the information is understood 1. In this case, the failure to communicate the schedule change to the surgeon and the patient led to a breakdown in the informed consent process, further supporting the conclusion that the defect is a booking defect. Key points to consider in this scenario include:
- The importance of closed-loop communication in preventing adverse events 1
- The need for effective communication between the scheduling team and the surgeon
- The importance of providing patients with sufficient information and time to make informed decisions 1
- The duty of the anaesthetist to ensure that the information is understood 1
From the Research
Analysis of the Scenario
The scenario presents a case where a patient scheduled for bilateral cochlear implantation is cancelled, but the surgeon is not informed and proceeds with the operation on the wrong side. The question is to identify the defect in this scenario.
Possible Defects
- Booking defect: This refers to an error in the scheduling or booking process, which can lead to mistakes such as wrong-site surgery.
- Marking defect: This refers to an error in the preoperative marking of the surgical site, which can also lead to wrong-site surgery.
Evidence from Studies
Studies have shown that wrong-site surgery can occur due to various factors, including inadequate preoperative marking 2, 3, 4, 5, 6. However, in this scenario, the defect is more likely related to a booking error rather than a marking error. The fact that the surgeon was not informed about the cancellation of the bilateral procedure and proceeded with the operation on the wrong side suggests a breakdown in communication or scheduling.
Key Points
- Wrong-site surgery can occur due to various factors, including booking errors and marking errors.
- Preoperative marking is an important step in preventing wrong-site surgery, but it is not foolproof 3, 4, 6.
- Booking errors can lead to mistakes such as wrong-site surgery, highlighting the importance of effective communication and scheduling processes.
Based on the analysis, the defect in this scenario is more likely a booking defect rather than a marking defect. The error occurred due to a breakdown in communication or scheduling, rather than an issue with preoperative marking.