F RO M T H E DATA B A S E Incorrect End Colostomy Formation Using the Distal Bowel Limb: A Rare but Serious Complication Michelle Feil, MSN, RN, CPPS Colectomy and surgical formation of an end colostomy involves bringing the proximal, Senior Patient Safety Analyst or afferent, bowel limb to the surface of the abdomen to create a stoma. The distal, or Pennsylvania Patient Safety Authority efferent bowel limb is either removed, or surgically closed and left inside the abdomen (Figure). Failure to accurately identify the correct bowel segment intraoperatively results in incorrect end colostomy formation using the distal bowel limb to create a stoma. Closing the proximal limb creates a blind pouch, which results in bowel obstruction that requires surgical correction. The frequency of this complication is not established in the literature,1-3 but is believed to be rare.4,5 Still, this error warrants attention because it can result in serious harm to patients, at a minimum allowing exposure to the risk of undergoing an additional surgical procedure, and at a maximum leading to bowel ischemia, perforation, sepsis, shock, and death.6 “This is a technical error that is very easy to make if you are not paying attention, and it is the one error that no colorectal surgeon wants to make,”7 explained Steven Fassler, MD, Chief of Colorectal Surgery at Abington Hospital—Jefferson Health, and former president of the Pennsylvania Society of Colorectal Surgeons. Colectomies can be performed using either an open or laparoscopic surgical approach. Laparoscopic colectomies have been steadily increasing since the 1990s, with nearly one-half of all colectomies in the United States performed using this approach.8 While this error can occur using either surgical approach, “It is much easier to make this mistake if you are performing the surgery laparoscopically,” said Fassler. “With an open case, you can visualize both ends. With a laparoscopic colectomy, it is easier to get turned around and pull up the wrong end.” Strategies exist to prevent this complication, but even when steps are taken to ensure proper end colostomy formation, this error can occur. Because of this, postoperative physical assessment of the stoma site and bowel function is key to recognizing this error, and prompt intervention is vital to ensure a viable, properly functioning colos- tomy. Bowel sounds should return within 24 to 72 hours of surgery, and drainage of Figure. Anatomy of Colostomy Formation Proximal, or afferent, bowel limb is brought to the surface of the abdomen to create a stoma. Distal, or efferent, bowel limb is closed and left inside the abdomen. MS16577 Note: This illustration shows a descending colostomy. Colostomies may be created at other points along the length of the colon. Page 118 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority ostomy effluent from a properly formed Table. Time from Initial Procedure to Surgical Revision for Colostomies Formed Using stoma should be seen within several days.9 Distal Bowel, as Reported through the Pennsylvania Patient Safety Reporting System, Prolonged postoperative ileus (>36 hours) 2006–2015 requires further evaluation.5 TIME INTERVAL EVENTS Less than 7 days 1 DATA OVERVIEW 7 days 2 Pennsylvania healthcare facilities reported 8 to 14 days 1 eight events involving incorrect end colos- tomy formation using the distal bowel More than 14 days 1 limb through the Pennsylvania Patient Not specified 3 Safety Authority’s Pennsylvania Patient Total 8 Safety Reporting System (PA-PSRS) over a 10-year period, from January 2006 through December 2015. Five of these events have been reported in the most than the proximal end of the colon is to leave the camera port in place, re- recent four years. was used to create the stoma. The insufflate the abdomen, and re-insert the patient was returned to the operating camera to perform a final check just prior All events were reported as Serious Events room for revision of the colostomy. to maturing the stoma. resulting in temporary harm, requiring treatment or intervention, and/or pro- Engaging other surgical team members to DISCUSSION perform an independent double-check of longed hospitalization. Primary and secondary strategies exist to the surgical site and mark is a principle Three of the event reports indicate that encouraged by the Authority to prevent prevent incorrect end colostomy forma- the initial surgery was performed laparo- wrong-site surgery.10 Asked whether this tion using the distal bowel limb. Primary scopically. The remainder do not indicate could be done during this procedure, prevention strategies are those that can whether the colostomies were created Fassler said, “I always have a second per- be taken intraoperatively to prevent the using an open or laparoscopic approach. son scrubbed—another surgeon, a surgical wrong bowel limb from being used to cre- Analysis of PA-PSRS event reports reveals ate the stoma, and secondary strategies are resident, or a first assistant—in addition variation in the time intervals between the those that can be taken postoperatively to to myself and the scrub nurse. During the initial colectomy procedures and subse- recognize that the error has occurred and procedure I verbally say, ‘This is the distal quent surgical revisions. (See Table.) intervene in a timely fashion to correct limb,’ and ask if they agree. It is not part The following is an example of an event the problem. of a standardized protocol, but more of reported through PA-PSRS.* Details a common-sense conversation with the included in the event-report narrative Primary Prevention people involved.” illustrate the harm to patients resulting Fassler emphasizes the importance of from this complication and describe the checking multiple times throughout the Secondary Prevention physical assessment findings that helped procedure that the proximal and distal Postoperative physical assessment is key the healthcare team to identify that this limbs are accurately identified. “I usually to recognizing that an end colostomy technical error had occurred: identify the proximal and distal limbs at has been incorrectly formed using the least six times during the procedure,” he distal bowel limb. Delayed recognition Postoperatively, the patient’s bowel said. Fassler uses several different tech- and failure to correct the resultant bowel function failed to resume and the niques to identify the distal and proximal obstruction in a timely fashion can result abdomen became progressively dis- bowel limbs intraoperatively. One is to in serious harm to patients, up to and tended. The patient developed fevers make a mark on the distal limb using including death.6 Although no deaths and hypotension prompting transfer cautery. The second involves inserting a were reported through PA-PSRS, it is to the intensive care unit. Diagnostic red rubber or urinary catheter into the concerning that half of the event reports testing revealed that the distal rather distal limb, infusing fluid, and checking describe situations in which the time that to see whether the fluid drains from the elapsed between the initial procedure and * The details of the PA-PSRS event narratives patient’s anus. And the third option, surgical revision was seven days or greater in this article have been modified to preserve used during a laparoscopic procedure, confidentiality. Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 119 ©2016 Pennsylvania Patient Safety Authority F RO M T H E DATA B A S E (see Table). More information is necessary —— Ensure that novice surgeons gain expressed through the stoma, the to understand why these delays occurred. proficiency in end colostomy for- colostomy has been incorrectly mation through supervised direct formed using the distal bowel limb.2,5 Reporting to Learn clinical experience, including during —— Monitor the patient postoperatively Learning from event reporting is a fun- laparoscopic training programs.5 to confirm the return of bowel damental patient safety principle11 and —— Mark the distal (or proximal) bowel sounds within 24 to 72 hours and the foundation of the Authority’s work. limb intraoperatively using either a the production of ostomy effluent Fassler agrees, explaining that he sees the suture5 or cautery.7 within the first several days.9 value in reporting surgical errors such —— Use the same method and mark —— Aside from absent or diminished as the one described in this analysis. the same bowel limb (i.e., either bowel sounds and lack of ostomy “Everyone thinks that reporting these proximal or distal) each time the effluent, assess the patient for addi- errors and complications is punitive, but procedure is performed.5 tional signs and symptoms of bowel we need to report and talk about these —— Ask surgical team members to con- obstruction, including abdominal situations so that we can learn from them firm identification of the proximal distension and pain.6 and prevent this from happening to other and distal bowel limbs whenever —— In patients with postoperative ileus patients.” In fact, Fassler would encour- possible.7 lasting more than 36 hours, consider age reporters to include as many details as instilling a contrast enema through —— Before closing the distal bowel limb, possible, particularly in complicated cases. the stoma to identify errors in colos- insert a red rubber or urinary cath- “Surgeons would like to know exactly tomy formation or other causes for eter into the distal limb, infuse fluid, what factors contributed to the mistake. obstruction.4,5 and check to see whether the fluid Because what we are really trying to do is drains from the patient’s anus.7 say ‘Hey, I may be facing a similar situation CONCLUSION in the future, and I want to know what I —— Toward the end of a laparoscopic procedure, reinsert the camera Incorrect end colostomy formation using could do to prevent something like this through the camera port, re-insufflate the distal bowel limb is a technical error from happening for me and my patient.’” the abdomen, and check to ensure that is believed to occur rarely. Events that the proximal bowel limb is being in which this error has occurred have RISK REDUCTION STRATEGIES pulled up to create the stoma.7 been reported to the Authority. Though The following are actions colorectal sur- —— After closing the distal bowel limb, rare, this error has the potential to result geons, nurses, and other surgical team insert a flexible sigmoidoscope or in serious harm to patients, up to and members can consider to prevent and/or colonoscope through the rectum to including death. Colorectal surgeons, identify and correct this technical error: visualize the staple/suture line and nurses, and other surgical team members —— Maintain vigilance when completing confirm creation of a blind pouch.2,5 can take action to prevent this error from the finer technical steps involved in occurring and/or recognize the error and —— Once the stoma has been formed stoma creation, and do not delegate intervene in a timely fashion to protect and opened at the end of the this task to junior or inexperienced patients from serious harm. operation, instill water or air into members of the surgical team with- the distal bowel limb through the out proper supervision.2,3 rectum. If colonic contents are Page 120 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority NOTES 1. Bafford AC, Irani JL. Management and New York, NY: McGraw-Hill; 2016 [cited 10. Clarke JR. Quarterly update: what might complications of stomas. Surg Clin North 2016 Aug 9]. http://accessmedicine. be the impact of using evidence-based Am 2013 Feb;93(1):145-66. mhmedical.com/content.aspx?bookid=16 best practices for preventing wrong-site 2. Shabbir J, Britton DC. Stoma complica- 58&Sectionid=109430820 surgery? Pa Patient Saf Advis [online]. tions: a literature overview. Colorectal Dis 7. Fassler, Steven (MD, Chief of Colorectal 2011 Sep [cited 2016 Jul 5]. http:// 2010 Oct;12(10):958-64. Surgery at Abington Memorial Hospital, patientsafetyauthority.org/ADVISO- Abington Jefferson Health, Abington, RIES/AdvisoryLibrary/2011/sep8(3)/ 3. Shellito PC. Complications of abdominal PA). Conversation with: Pennsylvania Pages/109.aspx stoma surgery. Dis Colon Rectum 1998 Dec;41(12):1562-72. Patient Safety Authority. 2016 Jun 13. 11. The Joint Commission. Patient safety 8. Juo Y, Hyder O, Haider AH, et al. Is mini- systems chapter for the hospital program. 4. Kann BR. Early stomal complications. Clin mally invasive colon resection better than In: 2015 Comprehensive Accreditation Colon Rectal Surg 2008 Feb;21(1):23-30. traditional approaches? First comprehen- Manual for Hospitals [online]. 2014:PS- 5. Agency for Healthcare Research and 1-PS-28 [cited 2016 Jul 5]. https://www. sive national examination with propensity Quality. Which end is which? [online]. jointcommission.org/patient_safety_sys- score matching [online]. JAMA Surg 2014 AHRQ web M & M 2003 Apr. [cited tems_chapter_for_the_hospital_program/ Feb;149(2):177–184 [cited 2016 Jul 5]. 2016 Jul 5]. https://psnet.ahrq.gov/ http://www.ncbi.nlm.nih.gov/pmc/ webmm/case/7/which-end-is-which articles/PMC4036435/ 6. Price TG, Orthober RJ. Bowel obstruc- 9. Butler DL. Early postoperative complica- tion. In: Tintinalli JE, Stapczynski J, Ma tions following ostomy surgery: a review. J O, et al., eds. Tintinalli’s emergency medi- Wound Ostomy Continence Nurs 2009 Sep- cine: a comprehensive study guide, 8e [online]. Oct;36(5):513-9. Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 121 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 3—September 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.