Outrageous medical errors
I’ve written before about medical errors. Recently there was a horrendous one, in which a man in Boston got an operation on the wrong part of his body. Other than underscoring the fact that humans are fallible, what can we learn from this terrible incident?
There are supposed to be safeguards in place to prevent this kind of thing from happening. The process can best be summarized as confirming the answers to these questions: Are we doing this to the right patient, doing the right procedure, and doing it in the right place? Clearly this ‘time-out’ step was not done in this case. The result was tragedy.
The CEO of the hospital immediately admitted and evaluated the error here. It makes interesting reading. He admits the error, but he also makes oblique excuses for it, citing how chaotic and pressured the environment was, implying that somehow lessons the culpability.
The problem with that, as Dr. Bob Wachter explains on his excellent blog, is that we should plan for chaos and a pressured environment. It’s the way things always are. Dr. Wachter is a noted authority on patient safety issues. He uses examples as varied as the airline industry and service at the International House of Pancakes to emphasize that we certainly can devise systems that protect individuals — both the patients from harm and the doctors from ourselves.