Mutual Matters

Case Study: Wrong Site Surgery

Posted by Hall B. Whitworth, Jr., MD on Oct 3, 2017 12:08:00 PM

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A 49-year-old man underwent a colonoscopy by a colorectal surgeon who identified a large, firm tumor causing partial narrowing, approximately 60-70 cm from the entry site. Pathology of this tumor was suspicious for carcinoma. In addition, a polypectomy was performed at a different location, and the site was tattooed. Pathology of this second site was consistent with tubulovillous adenoma.

Two weeks later, the same surgeon performed a partial colectomy of the tattooed area, believing it to be the marker for the tumor to be removed. On further consideration, after the procedure, the surgeon reviewed the colonoscopy and pathology reports and realized the wrong portion of the colon had been removed. The surgeon discussed this with the patient and family, and two days later a second surgery was performed. The patient initially did well after this second procedure, but on the 10th day, an anastomotic leak was discovered by barium enema. A third procedure was performed, finding adhesions and a severe inflammatory reaction which required a diverting loop ileostomy on the right side of the abdominal wall. One day after hospital discharge, the patient was readmitted for 2 days due to fever, abdominal pain, and bloody drainage.

Over the course of the next month, the patient had 3 separate ED evaluations for complaints of fever, dyspnea, weakness, and cough with continued antibiotic treatment for a diagnosis of bacterial pneumonia. An oncology consultation was obtained 10 weeks after the initial surgery.  Instead of chemotherapy, the oncologist recommended observation. After several surgical follow-up visits, the patient underwent closure of his ileostomy almost 7 months after surgery. Within 10 days after this closure, however, the patient was again seen in the ED with fever and redness at the closure site. Cultures were positive, and the patient was once again admitted, this time with a right lower quadrant abdominal abscess requiring incision and drainage. Two months later, the patient was noted to have metastatic cancer involving the liver, and an intravenous port was placed to facilitate chemotherapy. 

Find out the outcome of this wrong site surgery case and read about our patient safety recommendations to improve communcations and reduce risk by clicking below. 

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