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.
It appears that HFB needs an entire section devoted to medical error. This is not surprising in light of the thousands of Americans who die from preventable errors each year.
The latest comes from Tanzenia where confusion about patient names earned brain surgery for a twisted knee, and knee surgery for a migraine sufferer.
Mr Didas who had been admitted for a knee operation after a motorbike accident is still recovering from the ordeal – he ended up unconscious in intensive care after his head was wrongly operated on. And chronic migraine sufferer Emmanuel Mgaya is likewise, still recovering from his unplanned knee surgery. The blunder was blamed on both patients having the same first name.
But a hospital official, Juma Mkwawa said it was the worst scandal that had happened at Muhimbili hospital and that, “sharing a first name cannot be an excuse”. The two surgeons responsible have been suspended. (BBC)
Before anyone retreats into the comfort of “that wouldn’t happen here,” I suggest a look at the growing literature on similar medication names and their consequences.
It is easy to be the bearer of sad stories and ill tidings. I would rather on a note for a hopeful future. Below are researchers and companies dedicated to identifying and eliminating causes of medical error.
Please add more in the comments section if you know someone working in this important context.
Center Treats Wrong Side Of Patient’s Brain
DETROIT — A patient undergoing treatment at the Karmanos Cancer Institute in Detroit received a dose of radiation on the wrong side of the brain, according to a report filed with the United States Nuclear Regulatory Commission.
According to the report, a crucial piece of information was misread prior to treatment with a gamma knife, which delivers a targeted form of radiation therapy that zeros in on specific locations in the brain.
The patient went through a routine MRI (magnetic resonance imaging) scan of the brain just before the procedure, but went into the scanner “feet first,” rather than the standard practice of head first, the document said.
“The gamma knife-authorized medical physicist failed to recognize the scanning error when importing the MRI images into the Gamma Knife treatment planning computer, and subsequently registered them as head first,” the report said. “This resulted in the wrong side of the patient being targeted and treated.”
What went wrong? Deviation from standards (if there are standards)? Too-busy doctors? I’ll be interested to see who gets the blame.