We operated on the wrong organ – but hey, it’s OK.

By Tony Collins

When a surgeon operates on the wrong organ the NHS calls it “wrong site surgery” (a euphemism which makes it sound like an official part of a medical student’s curriculum).

A surgical intervention on the wrong organ could never be a source of reassuring news unless it’s in the board papers of an NHS trust.  NHS board papers are, more often than not, the source of good news announcements, statistics and graphs. Bad news is between the lines.

This was North Bristol NHS Trust’s account of what it said was a “surgical intervention [that] was performed on the wrong organ in a patient”. The operation was complex due to distortion of the patient’s anatomy. “This incident has resulted in some long term harm for the patient although the patient has since fully recovered.” The trust reports more reassuring news:

–  the patient has been fully informed

–   and given an apology

–    a full investigation has been carried out and lessons learnt

–   the consultant surgeon was experienced, and was assisted by another specialist

–   the World Health Organisation Surgical Safety Checklist was used correctly and as such, could not have prevented this error.

–  the case was discussed at directorate clinical governance meetings and disseminated widely to raise awareness of distorted anatomy with clinical staff.

–  the Clinical Risk Committee, Commissioners and the National Patient Safety Agency are assured that human error is an acceptable reason for this incident and that all procedures were carried out correctly.

Comment:

It sounds reassuring that all procedures had been carried out correctly, and that the World Health Organisation Surgical Safety Checklist was used correctly. But if a sleeping driver injures someone, should his colleagues be assured that he’d just put the car through an MoT and was driving under the speed limit?

Trust board papers need to connect with everyday reality. I’d venture to suggest they are not the place for announcements on managerial successes.

The same trust reported the separate case of an  “Unintended retention of a foreign object post surgical intervention”. The retained object was a small microvascular clamp and this was removed during a subsequent operation,

“which resulted in a satisfactory outcome for the patient”.  Good news then.

We wonder how the trust will report the findings from its investigation of recent IT troubles.

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