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Publication Type: Sentinel Event Alert
Single or Multiple Incident: Single
Date: 4/2/2012 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety incident where the wrong site was operated on. Patient A was planned for RIGHT ureterorenoscopy. The chief surgeon Dr. Y performed time-out, proceeded with the procedure but cannulated the LEFT ureter instead. He sought help from Dr. Z when difficulties were encountered. Dr. Z completed the LEFT ureterorenoscopy successfully. The procedure was complicated by contrast extravasation of the left kidney and a left JJ stent was inserted. The error of wrong side procedure was then identified before the patient left the theatre. Right ureterorenoscopy was immediately done and the patient was subsequently discharged uneventfully. Contributing factors included: 1. Inadequate preparation. 2. Lack of proper handover from Dr. Y to Dr. Z. 3. Inconvenient X-ray facilities in the operating theatre. 4. Failure of the scrub nurse to speak up despite awareness of the mistake. Recommendations to prevent similar patient safety incidents are provided.

Additional Details

JJ stent
contrast media

Wrong side procedure performed