British patient’s play button tattoo confused surgeons so much they almost operated on him in the WRONG place – but can you spot why?
- The unnamed patient had already been marked on the eve of his lung surgery
- But surgeons the next day were baffled when they saw his play symbol tattoo
- They had to use permanent marker on his shoulder to indicate the correct site
It may seem like an innocent-looking tattoo.
But the ‘play button’ inking on a British man’s chest could have led to a catastrophic blunder that saw him operated on in the wrong place.
The patient, whose identity is unknown, had already been marked on the eve of his lung surgery with an arrow on his right shoulder.
But surgeons the next day were baffled when they saw his tattoo – and had to double check where he was supposed to be going under the knife.
The team at St George’s Hospital, London then used permanent marker on the man’s right shoulder to indicate the correct site before the operation.
It may seem like an innocent-looking tattoo. But the ‘play button’ inking on a British man’s chest could have led to a catastrophic blunder that saw him operated on in the wrong place
The bizarre case intrigued the team of doctors so much they decided to publish it in the prestigious British Medical Journal Case Reports.
‘Potential to cause confusion’
Writing in the journal, the team led by Joy Edlin explained how the patient’s play symbol tattoo had ‘the potential to cause confusion’.
Even though the man’s inking ‘gave rise to quite a stir in the anaesthetic room and operating theatre’, surgeons learned a valuable lesson.
They wrote: ‘It [the tattoo] reminded the entire team of the importance of correct site marking, the five perioperative communication.’
What was wrong with the man?
The man had suffered a primary spontaneous pneumothorax – the collapse of one of his lungs, caused by air entering the pleural cavity.
Doctors decided to conduct video-assisted thorascopic surgery, so they could see inside his chest and lungs.
He then underwent a bullectomy (removal of a dilated air space called the bulla) and pleurectomy (removal of the pleura – to prevent a build-up of fluid).
WHAT IS A NEVER EVENT?
Never events represent a fraction of the 4.6 million surgical procedures carried out each year and only occur in one in 20,000 cases of surgery.
They include operating on the wrong body parts, mixing up organs and leaving surgical tools inside patients.
Such incident have even led to deaths, including that of Frank Hibbard, who had undergone cancer surgery in October 2001 at Luton and Dunstable Hospital.
Bungling medics left an 8cm-long piece of gauze inside his pelvis, which triggered a soft tissue cancer and led to the lorry driver’s death, aged just 69.
In 2015, Britain was called out for being one of the worst offenders for leaving items inside patients by the Organisation for Economic Co-operation and Development.
The man ‘recovered well’ and was discharged two days later.
The new case, co-authored by Robin Kanagasabay, was titled ‘Risk of operating on the wrong site: how to avoid a never event’.
A never event is defined as a catastrophic hospital blunders deemed so serious that it should never take place, such as operating on the wrong body parts.
Following guidelines
To avoid such a blunder, health officials advocate the use of standardised patient wristbands and the World Health Organization’s Surgical Safety Checklist.
The WHO measure, introduced a decade ago, was launched as a tool to improve the safety of surgery and prevent unnecessary deaths.
It helps medics ensure they don’t operate on the wrong patient, perform the wrong procedure or operate on the wrong part of their body.
The National Patient’s Safety Agency published its own five-step checklist in 2010 in an attempt to make surgery safer, including the steps: briefing, sign-in, time-out, sign-out and debriefing.
A staggering number of wrong site surgery events
But, despite the interventions, figures show there was 84 wrong site surgery events at English NHS hospitals between April and September last year.
Never events represent a fraction of the 4.6 million surgical procedures carried out each year and only occur in one in 20,000 cases of surgery.
Such incident have even led to deaths, including that of Frank Hibbard, who had undergone cancer surgery in October 2001 at Luton and Dunstable Hospital.
Bungling medics left an 8cm-long piece of gauze inside his pelvis, which triggered a soft tissue cancer and led to the lorry driver’s death, aged just 69.
In 2015, Britain was called out for being one of the worst offenders for leaving items inside patients by the Organisation for Economic Co-operation and Development.
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