More medical errors–Operating on the wrong side of the patient’s brain!

There sure seem to be lots of medical errors in the news lately. No mention of human factors:

The most recent case happened Friday when, according to the health department, the chief resident started brain surgery on the wrong side of an 82-year-old patient’s head. The patient was OK, the health department and hospital said.

In February, a different doctor performed neurosurgery on the wrong side of another patient’s head, said Andrea Bagnall-Degos, a health department spokeswoman. That patient was also OK, she said.

But in August, a patient died a few weeks after a third doctor performed brain surgery on the wrong side of his head. That surgery prompted the state to order the hospital to take a series of steps to ensure such a mistake would not happen again, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.

We can surmise from the short news article that the source of the problem seems to be working memory??

In addition to the fine, the state ordered the hospital to develop a neurosurgery checklist that includes information about the location of the surgery and a patient’s medical history, and to put in place a plan to train staff on the new checklist.

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3 thoughts on “More medical errors–Operating on the wrong side of the patient’s brain!”

  1. I wonder if any of these mistakes came from putting up the transparent scan backwards, or if it is the necessity of translating from scan to patient lying in another orientation.

  2. Well, X-rays typically have R/L orientation markers burned into their corners, but maybe it was left out in these?

  3. I highly recommend reading Dr. Sanjaya Kumar’s new book, Fatal Care: Survive in the US Health System, it highlights several medical errors and offers solutions. The book is very interesting and a good read.

    You can find it at Amazon.com or go to the website http://www.fatalcare.com.

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