Doctor disciplined for removing wrong kidney

[ERD50]

Quote:

Originally Posted by Rich_in_Tampa If you think about it, your humorous version shows that it's not as easy as just "using a checklist." .... I know, it's a stretch but people of good intention commit such errors unless the system makes it almost impossible to do so. Another issue: when you have used a given checklist 1000 times, it is hard to avoid not paying close attention to it. Aviation and nuclear power have among the best error prevention, detection and correction systems in the country. Medicine is making rapid gains but has a long way to go.

I think the medical profession has a lot to learn, aviation and nuclear are probably good places to learn from. Even the thought that there would not be some long established SOP on "X marks the spot" or "X marks - do not touch" is an indication of systemic problems. More to the point, "X" is a bad way to do it, "X" does not communicate a specific, non-ambiguous action, it requires a "decoder ring" to know what it means. Not good.

You're right, a checklist alone gets stale pretty quick, you need a checklist and checks-balances on that checklist that keeps people involved. Such as one person reading the list, another responding with data, not just "check, check, check, check...." (ooops, was that 4 'checks' or 5 'checks', ....whatever). It's tougher to get complacent with "Oxygen? - Oxygen reading 4.5"; " BP? - BP reading 110/85"; "Marking on limb to amputate? - 'cut here' marked on right arm to amputate at elbow, "save' marked on left arm", etc. ( fill in with much more official sounding medical lingo ).

We used closed-loop-checks-balances for things far less important than someone's organ or limb. I've been shocked at how lax the medical industry is on these things. A friend of ours is a pharmacist. I asked her about how the heck they know what to do with that scribble on an Rx pad. She said something causal like "Oh, there are typical meds and typical dosages, we know you wouldn't get 100mG of a certain medicine - must be 10mG because that's typical. If something looked out of the ordinary we would call the Doc". It was just unfathomable to me that there wouldn't be some formal checks-balances in something like that.

Now, when you present engineers with a checklist and checks-balances, some of them get offended. "I know what I'm doing - that's what you pay me for", some will say. They feel like you don't trust them, or they are being treated like children. I suspect this is an issue with a lot of Doctors. You have to get them to understand that it's not about "them", it's about having a system in place that can be relied on to limit errors. And if an error does occur, having a system in place means you have something to improve. Without a system, how do you make it 'better'? It's really hit-or-miss.

Quote:

Originally Posted by Moemg One of the problems is the incredible workload on the operating team. ... I know this is no excuse for the mistake that happened but to me with all the cut backs in hospitals I'm amazed that more mistakes do not happen .

I don't doubt it, but not many people claim they have a lot of extra time for extra checks-balances. But as I said above, w/o it, not only will 'stuff happen', but it won't get better, because there is no basis to build upon. We often found that well designed checks-balances reduced our workload, we knew who was doing what, knew if it was done, and didn't waste time doing things twice or waiting for something we thought was done already. Things ran smoother, with less stress, which means you apply more mental power to the things that really need it. You might catch something else that you may have missed because you were distracted by something that wasn't ready because you didn't have a check-list. It's not always a time adder. It can be a pain getting it started, but once you have a good system in place, you wonder how you lived w/o it. That was my experience. Checklists and checks-balances designed to help you get the job done, not just to say you have a checklist.

-ERD50

[M Paquette]

Quote:

Originally Posted by ERD50 Now, when you present engineers with a checklist and checks-balances, some of them get offended. "I know what I'm doing - that's what you pay me for", some will say. They feel like you don't trust them, or they are being treated like children. I suspect this is an issue with a lot of Doctors. You have to get them to understand that it's not about "them", it's about having a system in place that can be relied on to limit errors. And if an error does occur, having a system in place means you have something to improve. Without a system, how do you make it 'better'? It's really hit-or-miss.

Sad, but true. There's a certain amount of personal self-awareness needed to accept mundane things like checklists. There has to be an awareness that one is not actually infallible, and a willingness to accept that an externally imposed mechanism can improve one's own results.

That can be a hard thing for some folks.

[Moemg]

There are a lot of checklists in place in an Operating Room . The patient is identified and asked by the nurse , the anesthesiologist and the physician what surgery they are having and the patient points to the area . The area is then marked by the physician . When the patient gets to the OR they are again asked and before surgery starts all the team members need to be in agreement with what procedure is signed for and this is all carefully documented on checklists .

[Texas Proud]

Quote:

Originally Posted by Moemg There are a lot of checklists in place in an Operating Room . The patient is identified and asked by the nurse , the anesthesiologist and the physician what surgery they are having and the patient points to the area . The area is then marked by the physician . When the patient gets to the OR they are again asked and before surgery starts all the team members need to be in agreement with what procedure is signed for and this is all carefully documented on checklists .

If that is the case in all locations... then why are there so many 'failures'? Because SOMEONE in the OR should have said something when the doc started to do the wrong thing...

[Moemg]

Quote:

Originally Posted by Texas Proud If that is the case in all locations... then why are there so many 'failures'? Because SOMEONE in the OR should have said something when the doc started to do the wrong thing...

If the consent says the right side when it should have said the left side things happen .

[mark500]

I am glad to see the posts on this thread have avoided simply condemning the physician as an incompetent idiot that should be pelted with stones. Americans tend to shame and blame seemingly thinking that that will solve a problem.
Truth is, right and left are easy to get mixed up. Systems failure analysis will anticipate human errors as inevitable, but have mechanisms in place to prevent an error from harming a patient. The only way these mechanisms will become widespread is with unfetterred revelation and analysis of misses and near misses, something that will not ever happen until legal reforms occur.

[Nords]

Quote:

Originally Posted by Rich_in_Tampa ... and nuclear power have among the best error prevention, detection and correction systems in the country.

That could also be interpreted as the corporate version of "the end justifies the means".

A little-appreciated secret of the submarine force is that if you tend to be an autocratic, domineering authoritarian ("I know what I'm doing!!") then you will run yourself aground at flank speed, and that's not just a metaphorical expression. (Witnesses will say "Golly, admiral, I'm sorry it happened, but he said he knew what he was doing and I wasn't going to have him yell tell me that my information was wrong. Again.") Unfortunately if you're a bright, articulate, inspirational, inclusive, team-building leader then you will also run yourself aground at flank speed. ("Gee, admiral, I'm sorry it happened, but he always knew what he was doing and I just figured that my information was wrong.") The halo is just as bad as being the pointy-haired boss from hell.

The trick is to see criticism as a constructive means of self-improvement, and to make enough mistakes that people will never hesitate to question your actions.

The problem is that some of the members of these "forceful backup" programs take just a little too much joy and enthusiasm in their implementation...

[Texas Proud]

LOL Nords.... reminds me of a story my sister tells.... she used to give directions to her husband... you need to turn up ahead etc... he would grumble etc... one time he just let her have it and said to let him drive..

SOO, a few months later.. they were on a long trip... and he started to look around and asked her... where are we? She said "I don't know, you missed the turn over an hour ago"... she just let him keep driving!!!! He said she could tell him where to go from now on....

[ERD50]

Quote:

Originally Posted by Moemg There are a lot of checklists in place in an Operating Room ...

OK, but the impression that some of us got from your and RITs posts was that they were not in place to a large degree - no consensus on what "X" means for example.

Quote:

Originally Posted by Moemg If the consent says the right side when it should have said the left side things happen.

This is what I mean about checks & balances, rather than just check-lists. How is it that the consent (I assume you mean some kind of 'consent form' here? I don't know the medical lingo) could get to the OR with the wrong side marked ? Where was the closed-loop checks-balance to validate that it was correct?

-ERD50

[M Paquette]

Quote:

Originally Posted by Nords The problem is that some of the members of these "forceful backup" programs take just a little too much joy and enthusiasm in their implementation...

Well, yeah, but that's what made instructor duty at the prototype plants so fun! We could be enthusiastic without leaving a radioactive hole in the ocean...

"Can I run the drills this watch? Can I? Huh? Huh? Pleeeease? I want to start with an oil fire, then do a radioactive steam leak, then maybe a loss of all power..."

Anything to pack a bunch of Ensigns and E-4s into firefighting gear and breathing masks, in the dark, with no A/C and surrounded with hot steam lines...

Maybe that's what medical residencies are really all about?

[Moemg]

Quote:

Originally Posted by ERD50 . How is it that the consent (I assume you mean some kind of 'consent form' here? I don't know the medical lingo) could get to the OR with the wrong side marked ? Where was the closed-loop checks-balance to validate that it was correct? -ERD50

The surgeon exams the patient and orders the procedure based on the results of test that were done . His secretary calls the OR booking agent and books the procedure but what if she gets distracted and says right instead of left kidney . The patient is then booked for a right kidney removal . She arrives at the hospital in a state of anxiety plus she is borderline illiterate . The pre op nurse talks to the patient and gives her the consent to sign which says right kidney . She signs it . The anesthesiologist comes and talks to the patient and says what are you having done today and she says " Something with my kidney " and he says what kidney and she says "whatever I wrote down " . The surgeon arrives looks at the consent and asks the patient if she is having surgery on her right kidney she agrees . The OR nurse comes in and again asks what the patient is having . Finally They are in the OR and the surgeon takes out his notes and his X rays and realizes the mistake . So yes there are plenty of checks and balances in place but they are not fool proof and a lot of times it is the patient not the doctor at fault .

[Orchidflower]

Moemg, that just confirms all the more that the patient really does need to take some control, yes?

[teejayevans]

Quote:

Originally Posted by Moemg The surgeon exams the patient and orders the procedure based on the results of test that were done . His secretary calls the OR booking agent and books the procedure but what if she gets distracted and says right instead of left kidney . The patient is then booked for a right kidney removal . She arrives at the hospital in a state of anxiety plus she is borderline illiterate . The pre op nurse talks to the patient and gives her the consent to sign which says right kidney . She signs it . The anesthesiologist comes and talks to the patient and says what are you having done today and she says " Something with my kidney " and he says what kidney and she says "whatever I wrote down " . The surgeon arrives looks at the consent and asks the patient if she is having surgery on her right kidney she agrees . The OR nurse comes in and again asks what the patient is having . Finally They are in the OR and the surgeon takes out his notes and his X rays and realizes the mistake . So yes there are plenty of checks and balances in place but they are not fool proof and a lot of times it is the patient not the doctor at fault .

I talk to my surgeon in his office, discuss particulars, on the day of the surgery him again outside the OR and had a short review of what he was going to do and what I could expect.
Do people in non-emergency situations actually have no contact their surgeons??
TJ

[Moemg]

Quote:

Originally Posted by teejayevans I talk to my surgeon in his office, discuss particulars, on the day of the surgery him again outside the OR and had a short review of what he was going to do and what I could expect. Do people in non-emergency situations actually have no contact their surgeons?? TJ

They have contact with the physicians but they just do not get it . Whether it's because they are so afraid they are blocking it out or they are of real low intelligence and sometimes there is a language barrier and if the patient does not indicate that they do not understand it does not raise a red flag . Most of the board members are assuming everyone would understand their health decisions but that is just not the case . Luckily most of these patients are obvious to the staff but once in awhile they are not . I used to work in pre op in a Outpatient Center and I would call the patients in for their procedures . I can't tell you how many people especially older people would just answer to any name because they were anxious .

[Martha]

Good points Moe.

[ERD50]

Quote:

Originally Posted by Moemg The surgeon exams the patient and orders the procedure based on the results of test that were done . His secretary calls the OR booking agent and books the procedure but what if she gets distracted and says right instead of left kidney . The patient is then booked for a right kidney removal . She arrives at the hospital in a state of anxiety plus she is borderline illiterate . The pre op nurse talks to the patient ....

OK, now you are really scaring me. I'm with mn54, this is increasing my fear of entering an OR.

What you describe is checklist, but not a closed loop check/balance system. The closed-loop part is essential. What you have here is a bit like the game of "telephone" - one person talks with the next, and that person to the next, and who knows what the final communication is? Of course the patient is in a state of anxiety - they are about to be operated on! I sure wouldn't expect them to know their left from their right, or anything at that point, heck, they may already be under medication (maybe self administered ).

So what happens if the surgeon that orders the procedure is not the one performing the procedure? Seems like there is a real chance for the one closed-loop step to fail, since that was the only point that the entry/exit criteria were compared. And even in that case, they were compared by the same person, that's not good, you need independent verification.

Let me give an example of how we handled totally non-life-threatening procedures. Not even life-endangering, but maybe career endangering:

So marketing wants a special build of a product, with specific features enabled/disabled in the firmware for that product.

A) They have to fill out a standardized form, checking which features are to be enabled/disabled. The originator and their supervisor sign/date the form.

B) I review the form, and give it to an engineer to set up a build.

C) We build a sample, and a different engineer from the one that programs it runs a check program to validate that the product was built per specs. I review that validation, sign it if all is well, and it is returned to marketing, to validate that we built it as they expected.

D) Marketing checks the product with a separate validation system. They sign off on it, and then we are allowed to build a production quantity.

E) QC validates the production build against the spec.

F) Then it gets sent to the customer (actually, customer may have been part of the feedback loop earlier).

If the person doing the checking is the same one that "wrote the spec", there is increased chance of error. Independent, closed-loop validation is key. Anything else is an accident lawsuit waiting to happen.

-ERD50

[Moemg]

So basically engineers never make mistakes because of their terrific checks and balances .


Engineering's Ten Biggest Mistakes (Made By Monkeys)

[ERD50]

Quote:

Originally Posted by Moemg So basically engineers never make mistakes because of their terrific checks and balances . Engineering's Ten Biggest Mistakes (Made By Monkeys)

Of course not. But having good systems in place help reduce the number of mistakes, and provide a feedback mechanism to reduce the chance of repeating that mistake in the future. And when a mistake does slip by, you review the system to determine how that happened, and how you can improve the system.

The fact that we are all humans, and humans are mistake-prone, and subject to distraction is exactly why these systems are so important.

Are you actually disagreeing that well designed/implemented closed-loop checks/balances can reduce mistakes?

-ERD50

[Rich_by_the_Bay]

Just to get back to the core issues, there is cultural bias against some types of error reduction strategies among some members of any profession. So, the system actually has to address that very fact.

Examples include identifying the likeliest antagonists, involving them early and often in the development of the systems, and emphasizing the non-punitive aspects of how such a system works, and make them stakeholders in it.

For the few who just can't get on board, well maybe they need to move on.

But to just throw any system of checklists, double checking by subordinates, and other interventions at highly trained and experienced professionals without preparing them for it is bad policy.

[teejayevans]

Quote:

Originally Posted by Moemg I used to work in pre op in a Outpatient Center and I would call the patients in for their procedures . I can't tell you how many people especially older people would just answer to any name because they were anxious .

For out/in patient services, my hospital has a SOP:

• what's your birthday?
• what's your name?
• who's your doctor?
• and sometimes, why are you here?

Every person asks this and then they all scan your barcode and
whatever they are doing is recorded. Now I know how a Fedex
package feels , but I'm ok with that.

I'm not sure what they do when I'm unconscious?
TJ