Wrong Site Surgery - October 2020

Incident Summary

A 66 year old was seen in the dermatology unit on 14/10/2020 and listed for a biopsy of 3 lesions, 2 on right temple and 1 on left mid back. At the same time was listed for an excision of a lesion on the midline of her lower back. All four sites were marked. The histology form was completed by the referring clinician that stated the three sites that required a biopsy. On the same day the patient underwent 3 biopsies by the dermatology procedure nurse of the day.

The patient then attended for a day case excision of the 4th lesion (midline lower back) two days later on 16/10/2020. At this time, it was clear that the wrong lesion on the back had been biopsied on 14/10/2020. This lesion was the one which had been listed for excision. This was confirmed by the initial clinician who was called into the procedure room.

Root Cause

The lack of guidance and standards which meant that the nurse was unable to positively confirm biopsy/excision site based on reference points of sites marked and the lack of a body map or available photography.

 Lessons Learnt

• The importance of clarifying site of biopsies by using a body map
• The importance that skin lesions not for biopsy should be left unmarked.
• There should have been interventions introduced following the introduction of the National Safety Standards for invasive procedures

Recommendations

• Referring clinician to confirm lesions to be biopsied with a body map for clarity of lesions requiring biopsy
• Introduction of policies and guidelines in dermatology including Clinical Guideline for Dermatology Standards, Dermatology Surgical Standards, Clinical Guideline for Procedure room
• In light of the lack of evidence of any interventions following the introduction of National Safety Standards for invasive procedures there should be a Trust wide audit of all areas which these apply.

 Specialist Surgery Learning summary completed August 2021

Article ID: 290
Created: February 6, 2023
Last Updated: April 25, 2024

Online URL: https://elearning.cornwall.nhs.uk/site/kb/article.php?id=290