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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 7/1/2014 12:00:00 AM
Country: Hong Kong
This alert describes a patient safety incident of a diagnostic procedure performed on the wrong side body part. A female patient attended the Diagnostic Radiology Department for a scheduled ultrasound-guided fine needle aspiration (FNA) of her left breast nodule. On arrival, the attending nurse checked the patient's identity and read the referral form indicating the site of FNA: 'L2-3H'. The patient stated that she was going to have FNA on the right side and the attending nurse positioned the patient with her right breast exposed. The radiologist performed an ultrasound examination on the patient's right breast. Unable to identify any lesion at the 2 – 3 o'clock area, he performed FNA targeting the background breast tissue. The nurse recognized that a wrong side procedure had been performed after cross checking the request form with the radiographer. The error was then explained to the patient and FNA on the left side lesion was performed. Key contributing factors included the following: 1. Unclear role delineation while conducting the "TIME-OUT" procedure. 2. No verification of the operating side before the procedure. Recommendations to prevent similar patient safety incidents are provided.


Rules / Policies / Procedures
  1. Update the "TIME-OUT" procedure guidelines to better define the roles of team members.
  2. Revise the "TIME-OUT" checklist to include verification in side-specific procedures.
Training
  1. Reinforce training of staff on vigilant adherence to standard of practice.

Wrong Side Procedure