Wrong Site Surgery

Download Cause MapSurgery Performed on the Wrong Body Part (Wrong Site Surgery)

Cause Mapping Example:

Cause Map of Surgery on Wrong Body Part One of the most egregious medical errors is performing a surgery in the wrong location, or wrong site surgery. Not surprisingly, this has been named as one of the "never events" (i.e., events that should never happen) as defined by the National Quality Forum. We will look at all of the potential causes of wrong site surgeries by using the Cause Mapping process. This is known as a proactive Cause Map. The three steps of the Cause Mapping process are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions. Each step will be discussed below.

Step 1. Define the Problem

The first step of the Cause Mapping approach is to define the problem. Normally we'd do that by asking four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? However, since we are making a proactive Cause Map, the "when" isn't important. This map will show us how a wrong site surgery COULD happen, instead of how a specific wrong site surgery incident DID happen.

Once we've captured the basic information about the incident, we capture the impact to the goals. A wrong site surgery can potentially cause harm to patients, so this is an impact to the patient safety goal and the patient services goal. The compliance goal is impacted because this is a "never event". Lastly, the materials/labor goal is impacted because the procedure that was supposed to occur has to be repeated, and the incorrect procedure has to be fixed. The outline for wrong site surgeries is shown below.

Outline of Problem

Step 2. Identify the Causes (The Analysis)

During the analysis step, we break the incident down into causes, which are captured on the Cause Map. The Cause Map starts by writing down the goals that were affected as defined in the problem outline. A wrong site surgery impacts the patient safety and patient services goal, due to potential harm to patients. It also impacts the compliance goal, because it's a never event, and the materials/labor goal because the procedure has to be repeated, and the first procedure has to be fixed. These are the first cause-and-effect relationships of our Cause Map.

Identify the causes

The analysis can continue by asking Why questions and moving to the right of any of the cause-and-effect relationships above. In this example, the cause of all the impacts to the goals is that a surgery on the wrong site.

Cause Map

We continue to fill in the Cause Map by asking "why" questions to the right. There are some effects that may have more than one cause. If more than one cause is required to produce the effect, we join these causes with an "AND". If either cause could produce the effect, the causes are joined with an "OR". Surgery on the wrong site is caused by the surgeon operating on the wrong site, and no member of the surgical team stopping the operation. If either of these causes did not occur, the effect (wrong site surgery) would not occur. We will look at both of these causes in more detail.

Cause Map

The cause of a surgeon operating on the wrong site could be in the site was incorrectly located, possibly due to abnormal patient anatomy and/or morbid obesity, or because the surgeon believes the wrong site is the correct site.

Cause Map

The surgeon could believe the wrong site is actually the right site if the surgeon ignores the paperwork and markings, and/or if the paperwork is incorrect, or there is no paperwork, and the surgeon is unable to determine the site from the markings, OR the wrong site is marked.

Cause Map

Why would a surgeon ignore paperwork and markings? Sometimes the surgeon trusts his or her own memory. An exam might give conflicting results, or a faulty decision might be based on radiography. This has occurred when a radiograph is presented backwards, due to incorrect, or no markings, or is read backwards, and the reading is not double-checked.


Cause Map

Some reasons it might be impossible to determine the correct surgery site from markings: the site could be, or could appear to be unmarked, possibly because the markings are in a location covered during surgery. Or, the markings could be unclear, if the markings are smeared from prep work, or inconsistent markings are used, or there is more than one mark. This could happen if there were several surgeons involved in the operation, or if the "right" and "wrong" site were both marked.

Cause Map

Finally, the wrong site could be marked if the wrong site was identified, or the marking was applied incorrectly, AND the marking was not double-checked. (After all, if the marking was double-checked, the wrong site being marked should have been noticed.)


Cause Map

The wrong site could be identified during marking if the patient identifies the site incorrectly, due to patient confusion over the procedure (perhaps because it was not adequately explained) or the terminology. Or, the patient may not have been asked to identify the site (such as might occur during emergency surgery), and the site is determined incorrectly from the chart, not double-checked, and not correlated with the chart. You see that, generally, lots of things need to go wrong to result in a wrong site surgery.


Cause Map

The detail added to this map comes from a review of available case studies. However, your best asset for preventing incidents like these - your staff - can provide even more detail based on their own experiences or literature reviews. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.


Step 3. Select the Best Solutions (Reduce the Risk)

Once the Cause Map is built to a sufficient level of detail with supporting evidence the solutions step can be started. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. Possible solutions are placed directly on the Cause Map above the cause they control. An example of a solution attached to a cause is shown below.

Now we've built our Cause Map and added possible solutions. Shown below is a summary of the Cause Map we've put together above, including solutions.

Cause Map

You'll notice that we can take these solutions and put them together in a process map that shows us what we should be doing before surgery to prevent wrong-site surgeries.

Cause Map

You can see the summary Cause Map, the process map, and how they fit together by clicking on "download PDF" above.

Cause Mapping Improves Problem Solving Skills

The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.

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