Patient at Halifax Hospital has surgery on wrong leg

A patient woke up from surgery at Halifax Hospital Medical Center last month to find her surgeon had operated on the wrong leg.

But, that's not how the cardiovascular surgeon explained it to her, according to a report from Florida's Agency for Health Care Administration, which investigated the July 3 incident. Instead, the surgeon told the patient that her other leg needed to be done anyway. Then he asked her to sign a consent after the fact, according to the report.

Patient 34, as she is referred to in the agency's report, was admitted to the Daytona Beach hospital for vascular disease, which was causing pain in her left leg. She gave her consent to have vascular graft surgery on her left leg. But the surgical staff scheduled the procedure for her right leg.

The surgeon talked with the patient the night before about the left-leg procedure she was to have, and he marked her left leg with a pen, according to the report.

The operating room nurse supervisor said that when she talked to the patient before surgery, the patient said she was having her left leg done, "but [the nurse] still had it in her mind the right leg," the report said.

A nurse anesthetist caught the error after the operation was underway on the wrong leg. She told another nurse who told the surgeon to stop.

The surgeon then proceeded to operate on the left leg, according to the report.

The day after the surgery, the surgeon talked to the patient and her daughter. "I explained to them that the surgery was justified because of her history," the surgeon said, according to an interview with ACHA conducted three weeks after the error.

"I then explained to them that I performed the procedure on the left leg that we obtained the consent for originally, and I asked the patient to sign a consent for the procedure that was done on the right leg."

When asked if he told the patient the surgery was an error, he said, "No, what I described to the patient was that the right side surgery was justified. I did not use the term 'wrong-site surgery'…I was thinking more about myself and justifying what was done to the patient," he said, according to the report.

Two-week delay

Though the hospital administration knew of the error the day it occurred, it did not report it to AHCA for 15 days, according to the report.

"We had a wrong-site surgery. We had a system in place, but we did not proceed in the proper way," said hospital spokesman John Guthrie.

"We self reported. We're not denying it. We have policies in place, and training in place, but the system broke down because of the human element," he said.

Wrong-site surgeries are rare because hospitals have extensive cross-checks in place to verify the correct procedure is being done on the correct patient on the correct side. The last time Halifax had a wrong-site surgery was in 1999, on an incorrect finger, said Guthrie. Halifax Hospital's surgeons perform 8,000 operations a year.

In the first six months of this year, 35 patients in Florida have had operations on the wrong site, according to AHCA data. Six have had the wrong surgery performed, and in one case surgery was performed on the wrong patient.

When asked what took the hospital so long to report the error to state officials, Guthrie said the hospital reported within the allowed time frame, and didn't want to rush the process.

"We knew we were going to change people's lives based on root-cause analysis, so we wanted to find the root cause," Guthrie said.

'Serious threat'

After learning of the incident, the state health-care agency began an intense survey of the hospital from July 22 to July 25. Health officials interviewed the staff involved in the wrong-site surgery, the surgeon and the patient, and observed operating-room management and hygiene procedures.

Agency officials uncovered numerous problems at the 678-bed public hospital, including a cleaning person who washed down the operating room table with the same water she had just used to mop the floor, according to the report.

They also found expired medications on drug carts in use.

The surgeon involved is no longer on staff, said Guthrie. The hospital also suspended the operating-room team involved, and one of the team members no longer works for the hospital.

As a result of their findings, the agency concluded that the hospital was in a state of "immediate jeopardy." An agency letter to Halifax Hospital dated July 30 stated, "The conditions at your facility pose an immediate and serious threat to the health and safety of patients."

Based on the findings, the agency recommended to the federal Centers for Medicare and Medicaid that the hospital's provider agreement be terminated as of Saturday, Aug. 17.

A termination would mean that Halifax Hospital could no longer receive payments for Medicare or Medicaid patients, a population that comprises up to 70 percent of its patients, said Guthrie.

This article is courtesy of Orlando Sentinel.