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Inadvertent Castration
PERIOPERATIVE GRAND ROUNDS Inadvertent Castration The Case:
Discussion:
An 83-year-old man presented with a left groin mass “that had been there for years” but had recently increased in size. The patient described persistent aching in his left scrotal area, with no identifiable exacerbating or alleviating factors. He noted no change in bowel or bladder habits. No history was elicited or offered regarding previous genital surgery. A physical examination showed a 20-cm left groin mass with some superficial skin ulcerations. The mass was not tender and was not reducible. The right groin and scrotum were unremarkable. The patient underwent surgery with a preoperative diagnosis of direct left inguinal hernia. Exploration of the left groin revealed a relatively small direct hernia and a large left-sided hydrocele. The planned repair of the direct hernia was carried out, and, rather than draining or excising the hydrocele, the surgeon decided to perform a complete excision of the hydrocele, spermatic cord, and left testicle. The surgery was completed without complication. In the postanesthesia care unit, the surgeon discussed the changes to the planned procedure with the patient’s wife, who informed the surgeon that the patient’s right testicle had been removed after a traumatic injury many years earlier. In subsequent discussions with the patient and his wife about hormonal replacement, the patient said he had not been sexually active for several years. The patient was given information about the benefits of hormonal replacement on energy level, muscle mass, and bone density, regardless of sexual activity, and he elected to receive periodic, intramuscularly injected testosterone.
Adverse events occur during surgical admissions, with an estimated five to 10 incorrect procedures being performed daily in the United States.1 The extent to which faulty communication or planning contributes to this unacceptably high rate of medical injury remains poorly studied. In this case, the surgeon almost certainly never considered the possibility of the absence of the contralateral testicle. Similar errors have occurred in situations that involved a patient’s only remaining kidney, adrenal gland, or parathyroid. Moreover, similar cognitive errors—failing to systematically rule out unusual but critical issues before moving forward with a planned procedure or therapy—lead clinicians to fail to recognize and act upon crucial patient-specific factors, such as medication allergies, potential medication interactions, and religious preferences, as well as how such factors interact with comorbid illnesses. Most clinicians would have taken appropriate action had they accurately comprehended the situation, a state known as “situation awareness.”2 In medical accidents, gaps in situation awareness, lack of experience, and incomplete medical histories, rather than lack of knowledge, are often to blame.3 Combating cognitive errors and supporting situation awareness requires procedures and systems that account for the frailties of normal human cognition. When complex, multistep tasks are performed in any high-risk arena, the use of memory aids; checklists; and other error-preventive practices, such as placing mission-critical data (eg, the history and physical, operative plan, diagrams) in the environment, is essential. (continued on page 325)
This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by J. Forrest Calland, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, clinical associate professor, University of Texas Health Science Center, San Antonio, TX. (Citation: Calland JF. Inadvertent Castration. AHRQ WebM&M [serial online]. January 2004. http://www.webmm.ahrq.gov/case.aspx?caseID⫽41. Accessed December 17, 2009.)
422
AORN Journal ●
March 2010
Vol 91
No 3
© AORN, Inc, 2010
PERIOPERATIVE GRAND ROUNDS
www.aornjournal.org
(continued from page 422)
Within the surgical team, a lack of role clarity and ineffective communication can lead to compromised teamwork.4 An absence of a preprocedure team meeting, along with the communication omissions with the family, may have contributed to the safety breakdown that led to this patient’s castration. Simple strategies emerging from human factors research, such as preoperative pauses or team briefings, have the capacity to orient team members and enable them to speak up or challenge something that seems to fall outside the standard of care.5,6 A direct link between such practices and enhanced safety does not yet exist, but indirect evidence supports the common-sense notion that these practices could bolster medical safety. Mandatory team briefings, with invitations by the team leader for participants to step back and speak up if they perceive a gap in safety, are simple, non-resource-consuming interventions that protect patients.
Perioperative Points: To help avoid medical errors, perioperative personnel should
complete an accurate preoperative assessment and medical and surgical history, include the patient and his or her family members in surgical plans, participate in a preprocedure briefing as a team,
maintain active communication with all team members, promote an environment in which team members feel safe to speak up if they see that a problem is occurring, and conduct a postoperative root cause analysis of any sentinel events and take action to make sure similar errors do not occur.
References 1.
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-1034. 2. Baumann MR, Sniezek JA, Buerkle CA. Self-evaluation, stress, and performance: a model of decision making under acute stress. In: Salas E, Klein G, eds. Linking Expertise and Naturalistic Decision Making. Mahwah, NJ: Lawrence Erlbaum Associates; 2001:139-158. 3. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614-621. 4. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237):745-749. 5. Rouse WB, Cannon-Bowers JA, Salas E. The role of mental models in team performance in complex systems. IEEE Transactions on Systems, Man, and Cybernetics. 1992;22(6):1296-1308. http://www.csee.usf.edu/⬃murphy/ Courses/RAP/Review/Set3/related/rouse92.pdf. Accessed January 14, 2010. 6. Paige JT, Kozmenko V, Yang T, et al. The mobile mock operating room: bringing team training to the point of care. Agency for Health Care Research and Quality. http://www.ahrq.gov/downloads/pub/advances2/vol3/ Advances-Paige_6.pdf. Accessed January 14, 2010.
AORN Journal
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Discussion:
An 83-year-old man presented with a left groin mass “that had been there for years” but had recently increased in size. The patient described persistent aching in his left scrotal area, with no identifiable exacerbating or alleviating factors. He noted no change in bowel or bladder habits. No history was elicited or offered regarding previous genital surgery. A physical examination showed a 20-cm left groin mass with some superficial skin ulcerations. The mass was not tender and was not reducible. The right groin and scrotum were unremarkable. The patient underwent surgery with a preoperative diagnosis of direct left inguinal hernia. Exploration of the left groin revealed a relatively small direct hernia and a large left-sided hydrocele. The planned repair of the direct hernia was carried out, and, rather than draining or excising the hydrocele, the surgeon decided to perform a complete excision of the hydrocele, spermatic cord, and left testicle. The surgery was completed without complication. In the postanesthesia care unit, the surgeon discussed the changes to the planned procedure with the patient’s wife, who informed the surgeon that the patient’s right testicle had been removed after a traumatic injury many years earlier. In subsequent discussions with the patient and his wife about hormonal replacement, the patient said he had not been sexually active for several years. The patient was given information about the benefits of hormonal replacement on energy level, muscle mass, and bone density, regardless of sexual activity, and he elected to receive periodic, intramuscularly injected testosterone.
Adverse events occur during surgical admissions, with an estimated five to 10 incorrect procedures being performed daily in the United States.1 The extent to which faulty communication or planning contributes to this unacceptably high rate of medical injury remains poorly studied. In this case, the surgeon almost certainly never considered the possibility of the absence of the contralateral testicle. Similar errors have occurred in situations that involved a patient’s only remaining kidney, adrenal gland, or parathyroid. Moreover, similar cognitive errors—failing to systematically rule out unusual but critical issues before moving forward with a planned procedure or therapy—lead clinicians to fail to recognize and act upon crucial patient-specific factors, such as medication allergies, potential medication interactions, and religious preferences, as well as how such factors interact with comorbid illnesses. Most clinicians would have taken appropriate action had they accurately comprehended the situation, a state known as “situation awareness.”2 In medical accidents, gaps in situation awareness, lack of experience, and incomplete medical histories, rather than lack of knowledge, are often to blame.3 Combating cognitive errors and supporting situation awareness requires procedures and systems that account for the frailties of normal human cognition. When complex, multistep tasks are performed in any high-risk arena, the use of memory aids; checklists; and other error-preventive practices, such as placing mission-critical data (eg, the history and physical, operative plan, diagrams) in the environment, is essential. (continued on page 325)
This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by J. Forrest Calland, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, clinical associate professor, University of Texas Health Science Center, San Antonio, TX. (Citation: Calland JF. Inadvertent Castration. AHRQ WebM&M [serial online]. January 2004. http://www.webmm.ahrq.gov/case.aspx?caseID⫽41. Accessed December 17, 2009.)
422
AORN Journal ●
March 2010
Vol 91
No 3
© AORN, Inc, 2010
PERIOPERATIVE GRAND ROUNDS
www.aornjournal.org
(continued from page 422)
Within the surgical team, a lack of role clarity and ineffective communication can lead to compromised teamwork.4 An absence of a preprocedure team meeting, along with the communication omissions with the family, may have contributed to the safety breakdown that led to this patient’s castration. Simple strategies emerging from human factors research, such as preoperative pauses or team briefings, have the capacity to orient team members and enable them to speak up or challenge something that seems to fall outside the standard of care.5,6 A direct link between such practices and enhanced safety does not yet exist, but indirect evidence supports the common-sense notion that these practices could bolster medical safety. Mandatory team briefings, with invitations by the team leader for participants to step back and speak up if they perceive a gap in safety, are simple, non-resource-consuming interventions that protect patients.
Perioperative Points: To help avoid medical errors, perioperative personnel should
complete an accurate preoperative assessment and medical and surgical history, include the patient and his or her family members in surgical plans, participate in a preprocedure briefing as a team,
maintain active communication with all team members, promote an environment in which team members feel safe to speak up if they see that a problem is occurring, and conduct a postoperative root cause analysis of any sentinel events and take action to make sure similar errors do not occur.
References 1.
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-1034. 2. Baumann MR, Sniezek JA, Buerkle CA. Self-evaluation, stress, and performance: a model of decision making under acute stress. In: Salas E, Klein G, eds. Linking Expertise and Naturalistic Decision Making. Mahwah, NJ: Lawrence Erlbaum Associates; 2001:139-158. 3. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614-621. 4. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237):745-749. 5. Rouse WB, Cannon-Bowers JA, Salas E. The role of mental models in team performance in complex systems. IEEE Transactions on Systems, Man, and Cybernetics. 1992;22(6):1296-1308. http://www.csee.usf.edu/⬃murphy/ Courses/RAP/Review/Set3/related/rouse92.pdf. Accessed January 14, 2010. 6. Paige JT, Kozmenko V, Yang T, et al. The mobile mock operating room: bringing team training to the point of care. Agency for Health Care Research and Quality. http://www.ahrq.gov/downloads/pub/advances2/vol3/ Advances-Paige_6.pdf. Accessed January 14, 2010.
AORN Journal
325