For report and Essay Canthopexy case Sequence of eventsMarketing Research and Data Analysis

Mrs P a 76 year old lady was initially referred to the Ocular Plastics service in 2014. Since this time she had undergone four previous procedures, the latest being in December 2017. Mrs PS had attended regular follow up appointments prior to this time. On the 13 October 2019 she attended a further follow up appointment, during which it was identified that she required a right, lower lid tightening procedure (Canthopexy) and a biopsy of a small lesion to the side of her right eye. The decision was made to operate and she was consented for both procedures. At this point the Consultant who saw Mrs P in clinic completed a waiting list slip indicating what procedure she required, on which eye, the type of anaesthetic and how long they anticipated Mrs P surgery would take and obtained written consent for the procedure which correctly described the site and side of the surgery.

A date was then booked for Mrs P surgery and she was invited to attend her pre-assessment appointment on the 18 December 2019.  The necessary documentation and clinical investigations were completed at this time in preparation for her surgery.

On the 28 March 2019 Mrs P, was admitted to an Ophthalmology day ward at the local hospital in the late morning. Mrs P was the second patient for surgery on the afternoon theatre list.

On arrival at the day ward Mrs P was seen by a Doctor, who was not to be the operating surgeon, and signed another consent form for the planned right Canthopexy and excision of the lesion on the side of her right eye. A marking arrow was put onto the right side of her forehead in preparation for surgery at this time; the Doctor intended this arrow to mark laterality rather than site. Mrs P also expressed concern to the Doctor about a second lesion lateral to her left eye. At this time there was a lack of clarity regarding the nature of the lesion on the left side and whether this should be excised as well and the Consultant was asked to review Mrs P with a view to confirming that a biopsy on this lesion would be performed at the same time.

The team brief was then carried out. As is usual on a combined team brief was held with staff from theatres and the ophthalmology clean room as patients are booked into either venue and can be interchanged in the interests of efficiency.  Four patients were discussed during the team brief, two whose procedures were to go ahead in the clean room and two for theatre. The Doctor who had reviewed Mrs P earlier led the team brief in which she was discussed; during the team brief the Consultant informed the team that she would be reviewing Mrs P as she had another lesion which may require excision at the same time. The Surgeon operating on Mrs P was not present for the entire team brief as he had been delayed in his morning clinic which had overrun. He did not hear the discussion around Mrs P.

Following the team brief, and before the first case the Consultant responsible for Mrs P attended the ward to review her personally. The Consultant examined the lesion on the left side that Mrs P had mentioned to the Doctor earlier and made the decision that this lesion should also be biopsied during the operation. The consent form was amended by the Consultant to reflect this additional procedure and  both patient and the Consultant countersigned the amendment on the consent form.

Mrs P was again marked in preparation for her surgery by the Consultant with a marking arrow pointing to each of the two lesions for biopsy (one on the right and one on the left) in addition to the existing arrow on her right forehead. The change to Mrs P’s procedure was clearly personally communicated to the surgeon by the consultant after the team brief and before she left for her lunch after the first case.

The first case of the afternoon then went ahead successfully; it was described by the Consultant as a challenging, intense case which took a considerable length of time. An atmosphere of pressure around time and ensuring the list finished on time was felt to be evident by the team. This patient was then taken back to ward and the Surgeon who was later to operate on Mrs P proceeded to write up the operation notes.

After the first case the Consultant agreed with the Surgeon that he would carry out the second case unsupervised and reminded him about the addition of an excision biopsy on the left temple.

Mrs P was brought into the anaesthetic room whilst the Surgeon was still writing up the notes from the previous case. The initial patient safety checks which are usually completed in the anaesthetic room in ophthalmology as there is no reception area within the ophthalmology theatres were completed with the ward nurse present, who then left.  The safer surgery sign then commenced with the Anaesthetist and the Operating Department Practitioner (ODP) confirming Mrs P’s details and the planned procedure against the consent form. The ODP also confirmed with Mrs P what procedure she was expecting to have and checked that she had been marked ready for her surgery. The safer surgery sign in had already been completed by the time the Surgeon entered the anaesthetic room. In keeping with his understanding of the procedure’s he was to perform he administered the local anaesthetic as he would do to perform bilateral Canthopexy’s and bilateral excision biopsies, The Anaethetist left after this as is usual in cases requiring local anaesthetic only.

As the Scrub Nurse was preparing to scrub for Mrs P the Consultant informed her that a second lesion on the left was to be excised, and she left theatre to fetch the extra equipment required for the additional procedure. As the Scrub Nurse was completing her preparation the Surgeon entered the scrub area from the anaesthetic room and began to scrub whilst the ODP brought Mrs P into the theatre. The ODP asked if the team were happy to start the time out section of the safer surgery checklist, the Scrub Nurse, the Theatre Assistant and the Surgeon were present for the time out. The Surgeon confirmed that he was happy listening to the time out from the scrub room whilst he was washing his hands and preparing for surgery. The ODP read out Mrs P details whilst the Scrub Nurse confirmed them against the consent form. The Scrub Nurse then read out the procedure as per the consent form and confirmed that Mrs P had bilateral markings. The theatre team have confirmed that the correct procedures were read out; in spite of this the Surgeon believed that both the Canthopexy and the excision of lesions were to be undertaken bi-laterally.

During the time out the Scrub Nurse checked the white board and realised that it had not been completed to show the intended procedure. She asked the Theatre Assistant to write the procedure on the white board, the procedure was written as a left Canthopexy. The Surgeon would usually write the procedure on the board however he was already scrubbed in preparation for the case.

The ODP completed the anaesthetic element of the care plan at this point, without checking if the rest of the care plan had been completed.

The remainder of the time out checklist was completed and the procedure commenced with the Surgeon responding to a question from the scrub room. It is unclear at what point the Surgeon joined the team around Mrs P. The right Canthopexy was completed first followed by the right, temple excision biopsy. These two procedures were undertaken uneventfully and took approximately forty minutes. The Surgeon then moved to the left side of the patient and started to perform a left Canthopexy. It is not usual practice within Ophthalmology theatres for another time out moment to be repeated at this time. At the point that the Surgeon made the initial incision the Scrub Nurse immediately “stopped the line” and alerted the team of her concerns, questioning if the Canthopexy procedure should be bilateral.

The Surgeon immediately stopped and checked the white board in theatre which, he and the scrub nurse recall, said only left Canthopexy. The team then checked the consent form which correctly stated a right Canthopexy and bi-lateral excisions of lesions. On realising the error he closed the 1cm skin incision with dissolvable suture, before continuing to successfully perform the required left, temple excision biopsy.

An incident report form was completed on the day of the incident by the Surgeon. The theatre team informed the Deputy Team Leader of the incident who tried to contact the floor control to inform them of the situation, they were unable to do this as it was after 17:30hrs.