My life changing experience following wrong site surgery.
Abstract: Since being asked to write this article for the Journal of Perioperative Practice, I have been thinking a lot more about myself being a patient and not so much as a medical professional. Before this, being an Orthopaedic Nurse Practitioner took precedence as I couldn't get my head around being a patient or indeed that I had suffered as a result of wrong site surgery!

KEYWORDS Surgical safety checklist / Wrong site surgery / Fusion / Spine / Trauma
Article Type: Report
Subject: Medical errors (Personal narratives)
Medical errors (Prevention)
Nurses (Health aspects)
Nurses (Beliefs, opinions and attitudes)
Intervertebral disk displacement (Care and treatment)
Intervertebral disk displacement (Patient outcomes)
Spine (Surgery)
Spine (Personal narratives)
Spine (Cases)
Spine (Usage)
Spine (Patient outcomes)
Intervertebral disk (Hernia)
Intervertebral disk (Care and treatment)
Intervertebral disk (Patient outcomes)
Author: McMonagle, Claudia
Pub Date: 10/01/2009
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Oct, 2009 Source Volume: 19 Source Issue: 10
Topic: Event Code: 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Company legal issue
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Accession Number: 210725236
Full Text: My story started when I was diagnosed with a prolapsed disc at C5/6 in July 2007. Following a neurosurgical review (not the hospital that I worked in) I was listed to have a routine anterior cervical discectomy and fusion (ACDF). One week postoperatively, I was informed that they had removed the wrong disc; a healthy disc at the level above (at C4/5) instead of the prolapsed disc at C5/6. I returned to theatre three days later to have a revision ACDF to C4/5 as it was left unstable and to have the originally planned ACDF at C5/6 with metalwork inserted for stability.

It has taken me a long time to come to terms with what has happened to me; firstly, because I worked for the NHS, and secondly, because this was my specialty. I still cannot understand how a mistake like this could have been made. For legal reasons, I cannot divulge too much but, like many others, I am confident that had there been a 'Surgical Safety Checklist' it would have prevented this error.

Following these operations, which took place in September 2007, I now have a prolapsed disc directly under the two level fusions at C6/7. As a result of having wrong site surgery I have had a series of other invasive treatments such as epidural injections, facet joint injections and pulsed radio frequency, and I am still receiving treatment.

My life has changed so much over the past 19 months and so far there is no sign of things getting any better or indeed of me getting my life back. I have lost trust and confidence in myself as well as the NHS and as a result, all my treatment is now being done privately. Although I have the most amazing consultants looking after me now I do find it difficult at times and I cannot help but relive the past at regular intervals. The emotional scars will never heal and it will stay with me forever.

I have lost my job as an Orthopaedic Nurse Practitioner; the career that I loved and worked so hard for. I am not able to do certain activities that I would have previously done and would like to do, such as skiing and diving. I am unable to lift heavy objects and have lost some movement in my neck so turning around can be awkward, not to mention painful. I am in pain a lot of the time and have to take regular medication which has horrible side effects and does not always work. I am always feeling shattered and can't seem to stand for very long. I have to constantly shift my weight from one side of my body to the other! If I am out and about, I sometimes need to sit down and support my spine but I do find this embarrassing at times. I can no longer wear my high heel shoes which I love as they really hurt my spine.

Public transport is also a nightmare for me as I need to sit down but it is not always easy to find a seat. I find people looking at me in disgust when I don't offer my seat to an elderly person. They see a 33 year old who looks fit and well but they can't see my spine and don't know my story.

I have experienced many other problems since the surgery but the main ones have been mentioned. I think it is important to highlight these as quite often patients are forgotten about once they are discharged from hospital. Medical professionals don't always stop to think what it is really like for them; especially after wrong site surgery. It is not always just about the patient but also their families.

With the use of the 'Surgical Safety Checklist' I hope that wrong site surgery will become a thing of the past, and I urge each consultant/surgical team to please use it. It's not just for the safety of the patient but also for the clinicians themselves. It's so quick and easy to use!

No-one should ever have to go through what I have experienced.

Claudia McMonagle DipHE RN

Orthopaedic Nurse Practitioner

Correspondence address: c/o The Association for Perioperative Practise, Daisy Ayris House, 6 Grove Park Court, Harrogate, HG1 4DP. Email: wrongsitesurgery@googlemail.com
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