Wrong Leg Analysis

     Our perceptions of reality are often influenced by what we expect to see. Knowledge can be missing, inaccurate, or incomplete. Time pressures, workload, and reliance on past experience encourage acceptance of what appears to be complete information. Systems where information is fragmented are at risk of missing a piece of the puzzle. When information is stored in more that one location and can be changed in one place and not others there is an increased risk of error. Sometimes we don’t know what we don’t know or make assumptions without realizing the limits of our understanding. Knowledge may exist in a vacuum and be only partially correct. Without sharing information it is difficult to understand with clarity.
In the wrong leg amputation, knowledge was missing, incomplete and existing in a vacuum in the following ways:

• The OR schedule incorrectly listed the left leg amputation. This error was caught by the floor nurse and the computer generated scheduling form was corrected.
• The surgeon was not aware of the change and did not receive the updated form; the blackboard was not updated with the correct information.
• There was no cue that the wrong leg was being amputated because it was also diseased so surgery seemed appropriate. Chart review occurred during the procedure. The mistake was detected at this time, too late to prevent the surgery.