Page Section: Left Content Column
Page Section: Centre Content Column
Surgeon, theatre nurses and hospital failed to prevent wrong-site surgery (00HDC06857)
Download Surgeon, theatre nurses and hospital failed to prevent wrong-site surgery (00HDC06857) (PDF 13Kb)
(00HDC06857, 21 August 2002)
Surgeon ~ Anaesthetist ~ Nurses
~ Private hospital ~ Standard of care ~ Co-operation among
providers ~ Orthopaedic surgery ~ Wrong-site surgery ~ Rights 4(1),
A 67-year-old woman was admitted to hospital with a torn medial
meniscus in her right knee. The surgery was mistakenly performed on
her left knee. The responsibilities of the orthopaedic surgeon, the
anaesthetist, the anaesthetic nurse, the scrub nurse, and the
theatre nurse were considered.
The Commissioner held that it was primarily incumbent on the
orthopaedic surgeon to ensure he was operating on the correct knee.
Anything less than the correct operation, performed on the correct
site, prima facie amounts to negligence and is a breach of Right
4(1) of the Code.
The circulating theatre nurse, who noticed that the operation site
was not marked prior to surgery and brought this to the surgeon's
attention, was held to have breached Right 4(1) in failing to
prevent surgery on the incorrect leg. She was not entitled to rely
on the surgeon's knowledge of the omission, nor to assume the
omission had been corrected.
The scrub nurse noticed preoperatively that the surgical site was
not marked and was aware that this had been brought to the
surgeon's attention. When she assisted with the draping of the leg
she failed to notice that the operation was being performed on the
incorrect leg. She had an independent professional responsibility
to recognise the situation and to do what was reasonably within her
power to ensure the patient's safety. Individuals cannot
disassociate themselves from their own involvement in major errors
simply because they incorrectly take their lead from the mistakes
The anaesthetist, who involved himself in the consent process, and
was specifically aware that the surgery was to be performed on the
right knee, was considered to have unwittingly assumed more
responsibility than was appropriate.
However, he was not obliged to mark the operation site and at
critical times had other key anaesthetic responsibilities.
Likewise, as part of her preoperative duties, the anaesthetic nurse
confirmed that the right knee was to be operated on, but had duties
to attend to other than ensuring the correct progression of the
While each member of the theatre team had individual
responsibilities, the theatre team is not itself a legal entity and
did not breach Right 4(5).
The private hospital breached Right 4(1). As wrong-site surgery is
a well-recognised potential problem, the failure to specifically
acknowledge and attempt to minimise the risk by providing dedicated
policies amounted to an omission to provide surgical services with
reasonable care. The Commissioner is not bound by medical practice
prevailing at the relevant time but is entitled to demand stricter,
patient-focused standards. A common practice may still breach the
The Commissioner referred the matter to the Director of
Proceedings, who prosecuted the surgeon before the Medical
Practitioners Disciplinary Tribunal. The Tribunal dismissed the
charge of professional misconduct on the grounds that although the
consultant surgeon must bear primary responsibility for the error
that occurred, it was a chain of events involving a team of
providers that culminated in the adverse outcome.
Page Section: Right Content Column
Top of Page