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When It's Surgery, Don't Get It Wrong

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By Tracy Grant
Washington Post Staff Writer
Tuesday, July 22, 2008

"Mrs. Grant, this is Sarah. I'm calling to schedule the procedure on your son's right ear."

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The voice on the other end of the phone had the perky efficiency of a doctor's office nurse.

"You mean his left ear," I say.

"Well, the orders say the right ear, but don't worry, the doctor will check both ears on the morning of surgery."

Perhaps I should have been more upset at this medical mix-up, but as the mother of twins born two months premature, I am a veteran of medical bureaucracy, of -ologists of every ilk and, yes, of medical mistakes. (Once, before a surgery, it became clear that the medical student had read the wrong twin's medical history.) Besides, I've always had trouble telling right from left, so it occurred to me that the nurse was correct.

Apparently I'm not alone in having left/right issues. According to research done by John R. Clarke, a professor of surgery at Drexel University in Philadelphia and the clinical director of the Pennsylvania Patient Safety Reporting System, surgical mistakes involving the wrong side of the patient occur three times a day in the United States.

Although Clarke describes this as a significant problem even if it's "not particularly common," he points out that for 15 percent of adults, telling right from left is not automatic.

So when an error like this is suspected, "it behooves people to speak up," he says.

So that night I asked Andrew, "Which ear is your bad one?" I knew all too well that by asking that, I was going to get the "And you call yourself my mother?" look from my 12-year-old. "My left," he said with a sigh. He should know. It was more than two years ago that he was diagnosed with a cholesteatoma, a growth in his ear that was profoundly affecting his hearing. It would need to be removed at some point in a fairly delicate operation, but for now we were staving off the inevitable with a series of minor procedures.

Two days later I got another call, this time from an equally perky nurse at the surgery center, filling me in on the usual details about outpatient surgery. "Have him wear comfortable clothes, nothing to eat or drink after midnight, bring your insurance card." I felt a little foolish when, after she had finished her litany, I asked, "Could you tell me what ear it says is being operated on?"

"His right," she fairly well chirped.

"No, it should be his left."

"Well, it definitely says his right. The word 'right' is even highlighted," her tone rose in cheery emphasis.

I explained in my best, most level voice that this was incorrect and was assured it would be looked into.

Later that afternoon, I called the doctor's office back and identified myself. It was Sarah again. She sounded appreciably less perky.

"Is this Andrew's mother? Sue from the surgery center called. I explained to you that the doctor would look in both ears before operating."

Clearly, in her mind, I was overreacting to the notion that my son might have a completely healthy ear operated on.

Fast-forward a week to the day of surgery. As we're beckoned back into the prep room, I explain to the surgical nurse that there has been some confusion about which ear is being operated on. I want to be sure everyone understands that it's his left ear that is to be treated. She nods in an understanding but, yes, perky way.

The first person to come see us is the anesthesiologist. "We're going to put a mask on you, Andrew. You'll fall asleep, and then the doctor will operate on your right ear."

I suddenly felt as if Andrew wasn't the only person in the surgery center with a hearing problem.

I try very hard to keep my tone measured as I explain again that the problem is with his left ear. I don't want to -- as Andrew would put it -- cause "a scene," but I also realize that I have to be heard on this.

Outside the prep room, I hear voices -- and just a touch of tongue-clucking. "She's very concerned that we operate on the left ear." As if I am somehow being unreasonable.

The doctor comes in. The doctor who has followed Andrew's condition for more than two years looks down at the paperwork he's holding and says -- you guessed it -- "so, we're going to put the tube in his right ear."

I wheel around on him. "No, his left ear. He has only ever had problems with his left ear. The hearing loss is in his left ear."

He looks stunned and mutters something about going off to check the audiology report. Andrew is breathing in the anesthetic and drifting off when the doctor reenters the operating room, pen in hand. "The hearing loss is on the left," he says authoritatively as he crosses the word "right" off the surgical orders and writes in "left," underlined three times.

It's all I can do not to scream "Well, DUH."

As I leave the operating suite, I look at the schedule of procedures posted on the door. It's right there. "Grant, Andrew -- RT ear."

I walk to the waiting room shaking, knowing that if my training as a journalist hadn't taught me to question authority, if I were just a little more intimidated by people in surgical scrubs, if I didn't speak English fluently, my son would have had a perfectly normal ear operated on.

We want to trust doctors, especially when there's something wrong with a child. And we should trust doctors: Trust but verify.

It's understandable that so many of us fall into Lazarus syndrome: the belief that doctors are godlike miracle workers who should never be questioned. It's certainly easier to believe that than to worry that they're making mistakes. But heck, we question the checker at the Giant if we think we're being overcharged. Why wouldn't you question the doctor who is about to cut into your child?

What happened to Andrew doesn't even count in Clarke's statistics of three wrong-side surgical errors a day, because his case was a "near miss."

In a recent study, Clarke focused on these almost-mistakes. "We looked at near misses and compared them with events that did not get caught and went on to produce wrong-site surgery. The number one action that prevented the error from actually occurring was the patient or a family surrogate speaking up," Clarke said. "Family was far and away the best source of corrective information."

Asking questions -- and getting answers that you understand and are comfortable with -- is especially important with children. Whether your child is 12 months or 12 years, he is counting on you, the parent, to be his advocate.

Epilogue: So the obvious question is: Is Andrew still in the care of the doctor who nearly made this mistake? The perhaps surprising answer is yes. In fact, I think I know how the mistake may have started.

Andrew's regular ear doctor was sick the day of his last appointment before the surgery, and so he was seen by a doctor who didn't know his case. Perhaps in writing up her notes, she wrote "right" instead of "left." Or maybe the scheduling nurse wrote it down wrong. Wherever the mistake occurred, it went unnoticed by anyone but me and snowballed when medical staff and nurses failed to question the doctor.

Does that make it excusable? No. But it makes it understandable. One of the standards Clarke is pushing for is to ensure that all the documentation for a patient is consistent and that no medical professional relies just on the most recent piece of paper. Errors "occasionally occur in writing down the information on the medical record," Clarke said. This standard could have prevented the situation with Andrew, because his quite-thick medical record clearly documented the problem was with his left ear.

The best advice I ever got on this topic came from my pediatrician, a wonderful woman who is both doctor and mom. "Never let any medical professional say something about your child that doesn't seem right to you. No doctor will ever know your child as well as you do."

Tracy Grant is the editor of The Post's Weekend section. Comments:grantt@washpost.com.


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