Hanchanale Vishwanath, Rao Amrith Raj, Motiwala H, Karim O M A
Department of Urology, York Teaching Hospitals NHS Foundation Trust, York, UK.
Wexham Park Hospital, Slough, UK.
Urol Ann. 2014 Jan;6(1):57-62. doi: 10.4103/0974-7796.127031.
"Primum non nocere" (first do no harm): Hippocrates (c. 460 BC-377 BC). Wrong site surgery is the fourth commonest sentinel event after patient suicide, operative and post-operative complications, and medication errors. Misinterpretation of the clinic letters or radiology reports is the commonest reason for the wrong site being marked before surgery.
We analyzed 50 cases each of operations carried out on the kidney, ureter, and the testis. The side mentioned on clinic letters, the consent form, and radiology reports lists were also studied. The results were analyzed in detail to determine where the potential pitfalls were likely to arise.
A total of 803 clinic letters from 150 cases were reviewed. The side of disease was not documented in 8.71% and five patients had the wrong side mentioned in one of their clinic letters. In the radiology reports, the side was not mentioned in three cases and it was reported wrongly in two patients. No wrong side was ever consented for and no wrong side surgery was performed.
The side of surgery was not always indicated in clinic letter, theatre list, or the consent form despite the procedure being carried on a bilateral organ. As misinterpretation is a major cause of wrong side surgery, it is prudent that the side is mentioned every time in every clinic letter, consent form, and on the theatre list. The WHO surgical safety checklist has already been very effective in minimizing the wrong site surgery in the National Health Service.
“首要之务，勿伤患者”：希波克拉底（公元前460年 - 公元前377年）。手术部位错误是继患者自杀、手术及术后并发症和用药错误之后第四常见的警讯事件。对临床信函或放射学报告的误解是手术前标记错误手术部位的最常见原因。
我们分析了分别对肾脏、输尿管和睾丸进行的50例手术。还研究了临床信函、同意书和放射学报告清单中提及的手术侧别。对结果进行了详细分析，以确定可能出现潜在问题的地方。
共审查了150例患者的803封临床信函。8.71%的信函未记录疾病侧别，5例患者的一封临床信函中提及了错误的手术侧别。在放射学报告中，有3例未提及手术侧别，2例报告错误。从未有过同意错误手术侧别的情况，也未进行过错误手术侧别的手术。
尽管手术是在双侧器官上进行，但临床信函、手术安排表或同意书中并不总是注明手术侧别。由于误解是手术部位错误的主要原因，谨慎的做法是在每封临床信函、同意书和手术安排表中每次都提及手术侧别。世界卫生组织手术安全核查表在国家医疗服务体系中已经非常有效地减少了手术部位错误的发生。
