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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Patient record mistakes

LOS ANGELES – The recent chatter on a popular social networking site dealt with a problem often overlooked in medicine: mistakes in patients’ medical charts.The twist was the patients were doctors irked to discover gaffes in their own records and sloppy note-taking among their fellow physicians.

Errors can creep into medical charts in various ways. Doctors are often under time pressure and may find themselves taking shortcuts or not fully listening to a patient’s problems. Others rely on their memory to update their patients’ files at the end of the day. Other mistakes can arise from illegible handwriting or coding problems.

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“From the Doctor’s Brain to the Patient’s Vein”

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.

Warning compliance

[nytimes.com]

Authorities on the densely populated Indonesian island of Java concluded in mid-October that the threat was imminent enough to require sending troops to forcibly evacuate tens of thousands of villagers living on the mountain’s slopes, directly in the way of volcanic ash falls, mudslides and perhaps even lava flows …

that didn’t come. The government said on Thursday that the threat had now subsided enough for most evacuees to return to their homes and lands, and learn whether they had been looted or ruined over the weeks they were left untended.

In just two days, we’ve gotten two more big datapoints for the age-old quandary facing public officials around the world about where to set the threshold for public warnings of less-than-certain disaster.

There doesn’t seem to have been a crying-wolf issue in either case: both Mount Kelud eruptions and North Sea storm-surge floods have wrought devastation in living memory, and the authorities could offer plenty of objective physical grounds for their concerns.

Still, erring on the safe side takes its own toll, both material — the evacuated Indonesians apparently had ample cause to worry about looting — and psychological. Even when they are issued in good faith for good reason, every false alarm can drain some of the menace, and some of the effectiveness, out of the next warning.

“Set Phasers on Stun” still relevant in healthcare industry

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.”

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What went wrong? Deviation from standards (if there are standards)? Too-busy doctors? I’ll be interested to see who gets the blame.

Another precient post

The multiple monitor post made me think of something I read yesterday. This is from The Design of Everyday Things by Don Norman in 1988.

“Would you like a pocket-size device that reminded you of each appointment and daily event? I would. I am waiting for the day when portable computers become small enough that I can keep one with me at all times. I will definitely put all my reminding burdens upon it. It has to be small. It has to be convenient to use. And it has to be relatively powerful, at least by today’s standards. It has to have a full, standard typewriter keyboard and a reasonably large display. It needs good graphics, because that makes a tremendous difference in usability, and a lot of memory – a huge amount, actually. And it should be easy to hook up to the telephone; I need to connect it to my home and laboratory computers. Of course, it should be relatively inexpensive.”

When Norman wrote this, the “first PDA” had been on the market 4 years. Though armed with a full (though alphabetic) keyboard, it hardly fulfilled Norman’s ideals.

Today, of course, even the technologicaly challenged own one of these, only differing in that it IS a phone rather than having to hook it to one:

treo

One thing I find interesting: the device above fits Norman’s functional desires to a T. However, if there is anything that still needs usability improved… it is the cell phone.

And if there is anything that needs it more than a cell phone, it’s anything combined with a cell phone.

iphone usability

I apologize in advance for posting news about the iphone…but apparently, Perceptive Sciences (a usability firm in TX) concluded that the iphone has better usability than the Nokia N95 or HTC Touch

Everybody will have an opinion, but what’s need is something more objective and definitive. So an expert in the field — Perceptive Sciences, an Austin, Texas-based usability consulting firm — was asked to examine and compare the iPhone and two competitors.

The results of its tests were unequivocal: While the iPhone is not the most feature-rich device, this group of experts found that when it comes to usability, iPhone does, indeed, live up to its hype.

Not blaming the user since 2007!

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