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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 4/1/2020 12:00:00 AM
Country: Hong Kong

This alert describes a wrong side patient safety incident. A patient with pelviureteric junction stricture consented to an elective LEFT ureteroscopy and dilatation. Site marking was performed at the LEFT back and checked at the operating theatre reception area. ‘SIGN IN’ and ‘TIME OUT’ were performed. The doctor inserted the ureteroscope to the RIGHT ureter. As there were concurrent RIGHT distal ureter stricture and hydronephrosis of RIGHT kidney, RIGHT ureteroscopy and dilatation was performed. The doctor noted that the RIGHT instead of the intended LEFT side was performed after the procedure. The on-call specialist was consulted and decided to proceed to LEFT ureteroscopy and dilatation. It was documented on the operation record that bilateral procedures were performed and open disclosure was done. A recommendation to prevent similar incidents is provided.

Additional Details

Device:
ureteroscope


Wrong Patient / Part -- Wrong Side Ureteroscopy and Dilation