Unclear markings, failure to double check to blame for blunder which saw surgery done on wrong side of patient’s skull

Unclear marking of the surgical site and failure to double check were to blame for a medical blunder in which a doctor performed surgery on the wrong side of a patient’s skull.

Findings from an analysis of the episode at Princess Margaret Hospital in Kwai Chung on July 14 were released on Friday after investigations by a six-member panel.

The case, the second brain surgery blunder in public hospitals inside four months, involved an 86-year-old man who had been admitted to the neurosurgical ward on July 12.

He had sought medical assistance after suffering a subdural haematoma, a condition in which blood accumulates between layers of tissue around the brain. A burr hole operation should have been conducted on the patient’s left side to drain the blood, but was mistakenly done on the right.

Hong Kong brain surgeon drills hole in wrong side of patient’s head

Investigations showed the patient’s left ear lobe had been marked by a doctor on the ward to indicate the side for surgery before he was sent to the operating theatre.

While the operating team confirmed the patient’s identity and operating site, their scalp incision line marking was erroneously done on the right side.

The mistake was not noticed until minimal blood clotting was seen after opening the right side of the dura, a thick section of membrane outside the brain. The wound on the right side was then closed and surgery proceeded on the left side to drain the blood.

The patient resumed consciousness and was stable after the operation. He was discharged on July 24.

Princess Margaret Hospital explained the blunder to the patient and his family and apologised.

The panel said the blunder could have been introduced due to the marking on the left ear lobe, which was not clearly visible to the doctor from his position. Also, the side was not checked again before marking the incision lines.

Medical staff have been asked to mark the operation side on patients’ foreheads in future to improve clarity.

“Time out” procedures, meaning steps to confirm a patient’s identity and the correct site for operation, should also be performed twice before the incisions, recommendations stated.

The hospital will implement and follow up on the recommendations to prevent similar blunders, and work with relevant staff according to current human resources procedures.