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