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The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria
BACKGROUND: Wrong- site surgeries are iatrogenic errors encountered in the course of surgical patient management. Despite the ‘never do harm’ pledge in the ‘Hippocratic Oath’ drafted in 5(th) century BC, man is after all human, with this limitation manifesting in the physician’s art despite his best...
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Formato: | Online Artículo Texto |
Lenguaje: | English |
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BioMed Central
2015
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Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4312470/ https://www.ncbi.nlm.nih.gov/pubmed/25642288 http://dx.doi.org/10.1186/s13037-014-0053-2 |
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author | Nwosu, Arinze |
author_facet | Nwosu, Arinze |
author_sort | Nwosu, Arinze |
collection | PubMed |
description | BACKGROUND: Wrong- site surgeries are iatrogenic errors encountered in the course of surgical patient management. Despite the ‘never do harm’ pledge in the ‘Hippocratic Oath’ drafted in 5(th) century BC, man is after all human, with this limitation manifesting in the physician’s art despite his best intention. Beyond the catastrophic consequences of wrong- site surgery on the patient and surgeon, and the opprobrium on the art of medicine, the incidents have come to be regarded as a quality-of-care indicator. Orthopaedic surgery is a specialty with a preponderance of this phenomenon and the attendant medico-legal issues relating to malpractice claims. Consequently the specialty had pioneered institutional initiatives at preventing these ‘friendly-fires’. Awareness and implementation of these initiatives however remain low in many parts of the world, hampered by a culture of denial and shame. CASE PRESENTATION: This report presents two cases of wrong-site surgery following trauma from road-traffic accident. The first case was a closed reduction of the ‘wrong’ dislocated hip in the trauma/emergency unit under the care of senior residents, while the second case was attempted wrong-site surgery on the right leg in a patient with fracture of the left tibia, in conjunction with bilateral femoral fracture and right radio-ulnar fracture; by an experienced Chief Consultant Orthopaedic Surgeon operating elective list. Both are orthopaedic cases, each with some trauma to both lower extremeties. Neither of the cases was formally mentioned anywhere in clinical discourse in the hospital, much less a formal report or audit. CONCLUSION: There was no formal, institutionalized process to prevent wrong-site surgery in the health institution and this could have been largely responsible for these incidents. An open, mandatory process of reporting such incidents for relevant audit and awareness is necessary, as a mechanism for prevention rather than blame or punishment. |
format | Online Article Text |
id | pubmed-4312470 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2015 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-43124702015-02-01 The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria Nwosu, Arinze Patient Saf Surg Case Report BACKGROUND: Wrong- site surgeries are iatrogenic errors encountered in the course of surgical patient management. Despite the ‘never do harm’ pledge in the ‘Hippocratic Oath’ drafted in 5(th) century BC, man is after all human, with this limitation manifesting in the physician’s art despite his best intention. Beyond the catastrophic consequences of wrong- site surgery on the patient and surgeon, and the opprobrium on the art of medicine, the incidents have come to be regarded as a quality-of-care indicator. Orthopaedic surgery is a specialty with a preponderance of this phenomenon and the attendant medico-legal issues relating to malpractice claims. Consequently the specialty had pioneered institutional initiatives at preventing these ‘friendly-fires’. Awareness and implementation of these initiatives however remain low in many parts of the world, hampered by a culture of denial and shame. CASE PRESENTATION: This report presents two cases of wrong-site surgery following trauma from road-traffic accident. The first case was a closed reduction of the ‘wrong’ dislocated hip in the trauma/emergency unit under the care of senior residents, while the second case was attempted wrong-site surgery on the right leg in a patient with fracture of the left tibia, in conjunction with bilateral femoral fracture and right radio-ulnar fracture; by an experienced Chief Consultant Orthopaedic Surgeon operating elective list. Both are orthopaedic cases, each with some trauma to both lower extremeties. Neither of the cases was formally mentioned anywhere in clinical discourse in the hospital, much less a formal report or audit. CONCLUSION: There was no formal, institutionalized process to prevent wrong-site surgery in the health institution and this could have been largely responsible for these incidents. An open, mandatory process of reporting such incidents for relevant audit and awareness is necessary, as a mechanism for prevention rather than blame or punishment. BioMed Central 2015-01-31 /pmc/articles/PMC4312470/ /pubmed/25642288 http://dx.doi.org/10.1186/s13037-014-0053-2 Text en © Nwosu; licensee BioMed Central. 2015 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
spellingShingle | Case Report Nwosu, Arinze The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria |
title | The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria |
title_full | The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria |
title_fullStr | The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria |
title_full_unstemmed | The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria |
title_short | The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria |
title_sort | horror of wrong-site surgery continues: report of two cases in a regional trauma centre in nigeria |
topic | Case Report |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4312470/ https://www.ncbi.nlm.nih.gov/pubmed/25642288 http://dx.doi.org/10.1186/s13037-014-0053-2 |
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