A dermatologist is under the spotlight of New Zealand's health watchdog after performing surgery on a woman's old scar instead of her skin cancer. Photo / 123rf
A dermatologist is under the spotlight of New Zealand's health watchdog after performing surgery on a woman's old scar instead of her skin cancer. Photo / 123rf
A dermatologist is under the spotlight of New Zealand's health watchdog after performing surgery on a woman's old scar instead of her skin cancer.
The woman, in her 40s during the incident in 2018, was referred to the dermatologist after a lesion was found on the left side of her forehead.
On November 6, 2018, she underwent Mohs micrographic surgery to remove the skin cancer. But, 24 hours after surgery, when the woman's dressings were being changed, it was discovered the dermatologist had performed the surgery on the wrong part of her forehead.
Instead, the dermatologist had performed surgery on an old chickenpox scar above the cancerous part of the forehead.
Today, a report from the Health and Disability Commissioner (HDC) Rose Wall found the dermatologist in breach of the Code of Health and Disability Services Consumers' Rights for his failure in his care of the woman.
The report found the dermatologist failed to confirm the cancerous site with the patient by holding a mirror or reviewing the previous photograph of the skin cancer site.
The dermatologist stated he "reviewed the photograph at the prior site in a different room, not in the operating room where [the patient] was present".
He told the HDC his usual practice is to confirm the site of the operation together with the patient, but that this did not happen because the patient was given anti-anxiety sedatives, stating that her cognition was impaired.
In the report, Wall said the dermatologist failed to provide appropriate care for the patient.
"This report highlights the basic requirement of undertaking appropriate checks to ensure surgery is performed at the correct site.
"By failing to confirm the site of surgery correctly and subsequently performing the surgery at the wrong site, the dermatologist failed to provide the woman with an appropriate standard of care."
A dermatologist is under the spotlight of New Zealand's health watchdog after performing surgery on a woman's old scar instead of her skin cancer. Photo / 123rf
The dermatologist said he "deeply regrets" the incident and that he did not follow his usual process.
He told the HDC that in 30 years of performing Mohs surgeries he has never had this happen to him.
"It is regrettable that this set of events occurred and I have no hesitation in apologising to [the patient] again for excising the wrong lesion and for any upset and distress caused to her as a result.
"I acknowledge that operating at the correct site for any surgical procedure is fundamental ...
"This case has been a salutary lesson for me and as a result I have implemented a number of changes in my practice to avoid any such event from happening again in the future.
"I remain very sorry for [the] upset and distress caused to [the patient]."
The patient told the HDC she had to undergo further corrective surgery to her forehead, was has "been very traumatic" for her.
It was determined the incident was an individual error and did not signal any wider organisational issues at the dermatology clinic.
Wall recommended that the dermatologist arranges for an audit of the next three months of the Mohs surgeries he performs, to ensure that new additions to the consent form and intra-operative theatre record are being used.
