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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 1/1/2014 12:00:00 AM
Country: Hong Kong
This alert discusses a patient safety incident of wrong site procedure. The incident is described. The admission slip indicated RIGHT Pleural Effusion. The attending doctor documented "RIGHT Pleural Effusion" under X-ray findings while putting down "LEFT Pleural Effusion" as the diagnosis in the medical record. The consent form for ultrasound-guided chest tapping indicated"LEFT Pleural Effusion". The procedure safety checklist for chest tapping was performed using the consent form without site marking. Ultrasound-guided chest tapping was performed on the LEFT side. Post-procedural X-ray showed small left pneumothorax. A chest drain was inserted and the left lung was fully expanded. The attending doctor reviewed the post-procedural X-Ray films and discovered the error. The patient recovered uneventfully. The key contributing factors to the incident were as follows: 1. Lack of verification on the side of procedure and site marking. 2. Lack of standards of practice on performing ultrasound-guided chest tapping. Recommendations to prevent similar patient safety incidents are provided.


Rules / Policies / Procedures
  1. Verify the side of the procedure as indicated in all documents and images.
  2. Review and standardize the practice of performing ultrasound-guided chest tapping.

Wrong Side Chest Tapping