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Wrong side biopsy | Signal

Reference number
1140 H
Issue date27 November 2009
TypeSignal

This Signal relates to 14 cases of biopsies (e.g. breast, lung, kidney) carried out on the wrong side of the patient in range of hospital settings.

 

Biopsies are invasive procedures needed to diagnose diseases, such as cancer. These are often done on general wards and radiology/ultrasound departments as well as in theatre.

 

A typical incident reads:

 

“Request for CT/US guided renal biopsy – no side specified.  A functional left renal biopsy was performed and not the right renal cancer biopsy required.”

 

Following a trigger incident of wrong renal biopsy, a review of the wider incident database revealed 14 actual cases of wrong biopsy. This included a range of procedures from breast, lung, kidney and other. In all cases, this required a repeat biopsy and caused a possible delay in diagnosis and treatment. The database contains further ‘near miss’ incidents where final checks (showing inconsistencies between consent, notes and theatre lists) prevented biopsies being carried out on the wrong side.

 

This is a parallel issue to wrong-site surgery, which has been identified as a ‘Never Event’. 

 

The principles in the WHO surgical safety checklist should be followed to confirm identity, site, procedure and consent (including marking). The checklist also includes checking that essential imaging is available and displayed. Many biopsies happen outside theatres, where these principles may not be well known. However, the National Reporting and Learning Service (NRLS) is currently undertaking work to extend the safer surgery checklist to endoscopy and radiology departments. 

 

Some of the occurrences of wrong-side biopsies reviewed here suggest that more could be done to learn from these incidents in terms of reviewing processes. For example, one incident concludes: "I spoke to Dr x and Dr y and requested them to take care not to repeat same mistake in the future following pleural biopsy on wrong side”.

 

Other system issues concern access to equipment. In one case, ultrasound guidance was requested to do a renal biopsy but this was not available at time of procedure.

 

Have you had any incidents like this or local investigations to share? Please contact us at rrr@npsa.nhs.uk.

 

Relevant to: general medicine, surgery, radiology.

 


 

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