Wrong Limb: What Do You Know and When Did You Learn It?

As reported in the general media recently, the Joint Commission on Accreditation of Healthcare Organizations has embarked on a new tack to reduce the number of wrong-site surgeries. Not satisfied with past efforts to educate physicians on how to avoid these mistakes, JCAHO's message is that patients should join in helping their doctors avoid operating on the wrong limb.

But sometimes it takes a trial to determine exactly which health care provider will be held responsible for such errors.

A 37-year-old restaurateur consented to surgery on his right foot to remove a bone spur.

On the day of the scheduled surgery, Dr. S, the surgeon, saw the patient in the hallway outside the operating room and pulled up on the patient's blanket to observe his feet. Dr. S saw one foot covered with a surgical booty, with the other not. Dr. S assumed that the missing booty had fallen off. The anesthesiologist, Dr. A, then met with the patient and identified the side of the body to be operated on. Dr. A and a nurse then placed the patient in the prone position for surgery on the right heel.

By the time Dr. S entered the operating room, the patient was under anesthesia. He found the patient's left foot exposed and the right foot covered in sterile drapes. There were no booties on either foot.

Dr. S proceeded with surgery on the left foot, on which he noticed an osseous prominence. It was not until the patient was in recovery that Dr. S, while writing his post-operative orders, realized that he had operated on the wrong foot. When the patient awoke, Dr S told him of the error and apologized. Though Dr. S recommended waiting, the patient elected to have the correct surgery performed on the right foot the next day.

Post-operatively, the patient complained of pain in the left foot and filed a lawsuit against the hospital, Dr. S and Dr. A. With Dr. S and the hospital resolving their dispute outside of court, the case went to trial against Dr. A alone.

At trial, it was undisputed that Dr. A had properly identified the side of the surgery to be performed. Also, it was undisputed that the anesthesiologist did not have responsibility to prepare and drape the surgical site. Plaintiff's expert testified, however, that Dr. A fell below the standard of care because he failed to scan the operative field during surgery. Had he used such "reasonable diligence," the expert told the jury, Dr. A would have observed that the left foot was being incorrectly operated on. In a 9-3 vote, the jury found no negligence by Dr. A.

Since the incident, the hospital has put into practice a system recommended by the JCAHO - marking "yes" on the correct side of surgery and "no" on the other.
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Gordon Ownby is CAP-MPT’s general counsel. Comments on Case of the Month may be directed to gownby@cap-mpt.com.