Question

A patient is taken in for surgery on his right leg, but his left leg is operated on instead.

who worked with the patient are involved in the root-cause analysis.

Answer 1

All staff who worked with the patient should be involved in the root-cause analysis.

Who that typically includes
- Operating surgeon(s) and any assisting surgeons or residents
- Anesthesiologist and anesthesia assistants
- Scrub nurse/technologist and circulating nurse
- Pre-op/perioperative nurse(s) who performed assessment and site verification
- Staff who performed the site marking (if different)
- Ward/clinic nurse or admitting clerk who completed pre-op paperwork or verification
- Scheduling/booking staff and the person who entered the procedure into the OR schedule/EHR
- Transport staff who moved the patient to the OR
- Radiology/imaging staff if images were used for laterality verification
- OR manager/perioperative services leadership
- Patient safety officer and risk management representative
- Quality improvement/human factors specialist (for system analysis)
- Trainees and any other ancillary staff who were present (e.g., device reps)
- Patient and/or family representative (to include patient perspective when appropriate)

What the RCA should do (brief)
- Reconstruct the timeline and everyone’s actions/decisions
- Review documentation, consent forms, schedule entries, and imaging
- Interview involved staff in a nonpunitive way to understand workflow and communication failures
- Assess system factors: site-marking policy, timeout compliance, EHR/scheduling design, staffing/handovers, education and supervision, environment (lighting, interruptions)
- Develop corrective actions (policy changes, checklists, forced EHR prompts, training, audits) and assign responsibility and timelines
- Monitor effectiveness and share lessons learned transparently

A nonpunitive, systems-focused approach with broad participation yields the best chance of identifying root causes and preventing recurrence.