Wrong Leg Overview

     “You know which one it is, don’t you? I don’t want to wake up and find the wrong one gone.” Willie King’s joke on February 20, 1995 proved shockingly prophetic. Later that day, after signing the consent for surgery on his right leg and verbally confirming this with the nurse, the wrong leg was amputated. True, the leg taken off was diseased by the diabetes that wracked his body but recovery was possible. King relied on the left leg for mobility.

     King was 51 years old with a history of health problems, including insulin dependent diabetes. Early in February 1995, gangrenous changes were noted in his right foot and both feet were cold to the touch. Pain in his right foot was persistent and severe and did not respond to treatment. On February 17, King agreed to amputation of his right foot below the knee.

     The surgery protocol at the hospital was for surgeries to be scheduled by a clerk who entered the patient information in the computer record. Surgeries scheduled for the day were identified by printed schedule generated from the computer records. For each surgery, the schedule identified the assigned operating room, the surgical procedure, and the names of the patient, surgeon, and anesthesiologist. A copy of the schedule was located at the control desk staffed by an assistant nurse manager and a secretary. Information was also written on a blackboard. The fractionating of information in different areas contributed to this error.

     The printed surgical schedule incorrectly stated that King was to undergo a left below knee amputation. The reason for this error was never identified. The floor nurse from King’s unit caught the error and at 3:30 PM called to inform the surgical pool nurse that surgery was incorrectly identified on the schedule. The pool nurse corrected the computer-generated form.

     Hospital procedures required any change to a surgical schedule be submitted to the surgeon or his office. There is no evidence that the surgeon was aware of the change. The corrected copy of the schedule was on the clipboard and turned over to the relief nurse at shift change. An uncorrected copy was placed in King’s operating room. The circulating nurse was responsible for identifying the correct patient for surgery She spoke with King about the procedure and he identified that the right leg was to be amputated. The nurse noted this in his record. King’s left leg was also diseased but provided him with some mobility.

     At 5:45, over two hours after the error had been detected by the floor nurse, surgery commenced. Normal operating hours are 7AM to 3PM. While the operation was in progress, the circulating nurse began to review King’s medical record which indicated that surgery was scheduled for the right leg. She immediately looked at the surgery and realized that the wrong leg was being amputated. The amputation had passed the stage of reversal and was completed.