A 54-year-old woman is admitted to an outpatient surgical center for arthroplasty of the right knee. She is a former professional tennis player and has struggled with pain and stiffness in her knee for many years after multiple meniscal injuries in her early 30s. She is married to an attorney who has been very involved in her care but has frequently questioned the decision-making of her physicians. In the operating room, the surgeon performs a "time-out" procedure to confirm the details of the surgery. He announces that he will operate on the left knee, which is confirmed by the anesthesiologist. The surgical nurse double checks the patient's chart and corrects the surgeon that the operation is for the right knee, not the left. The surgeon notes this error and proceeds to perform the procedure on the correct side. Which of the following actions should be taken in response to this error?

Question

A 54-year-old woman is admitted to an outpatient surgical center for arthroplasty of the right knee.  She is a former professional tennis player and has struggled with pain and stiffness in her knee for many years after multiple meniscal injuries in her early 30s.  She is married to an attorney who has been very involved in her care but has frequently questioned the decision-making of her physicians.  In the operating room, the surgeon performs a "time-out" procedure to confirm the details of the surgery.  He announces that he will operate on the left knee, which is confirmed by the anesthesiologist.  The surgical nurse double checks the patient's chart and corrects the surgeon that the operation is for the right knee, not the left.  The surgeon notes this error and proceeds to perform the procedure on the correct side.  Which of the following actions should be taken in response to this error?

Quizplus · Accepted Answer

Explanation: This scenario is characterized as a "near-miss event," a type of medical error which, as a result of timely intervention or simply circumstance, did not reach the patient and no harm occurred. For approximately every 300 near misses, 1 adverse outcome occurs, indicating that analysis of near-miss events can be helpful in improving overall patient safety. For this reason, near-miss events should be reported to administration to ensure that adequate measures are taken to prevent other practitioners from making the same error. Disclosure to the patient should be determined on a case-by-case basis by the individual practitioner. In general, disclosure is recommended if there is a related, ongoing safety threat to the patient (potential for harm) or if the patient is aware of the near miss and disclosure will decrease anxiety and improve trust. (Choice A) Although there was no harm to the patient, the incident should be reported to hospital administration for analysis and prevention of similar potential errors. (Choices B and C) Disclosure to the patient and/or her husband is not mandatory. However, if the patient is aware of a near miss or if there is any potential for further harm, disclosure is advisable to preserve the physician-patient relationship. (Choice E) A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Examples include in-hospital suicide, abduction, discharge of an infant to the wrong family, or surgery performed on the wrong site or person. Although not all sentinel events result from medical errors, it is important for hospital administration to examine whether they could have been prevented to ensure future patient safety. Educational objective: Near-miss events involve medical errors that are caught before they reach the patient, causing no harm. Reporting of near-miss events is crucial in preventing more dangerous outcomes in the future, including events that cause death or serious injury.

A 54-Year-Old Woman Is Admitted to an Outpatient Surgical Center