Medical Error: Doctor Removed the Wrong Organ
A woman who was supposed to have her diseased kidney removed discovered that the surgeon had instead made a medical error and removed her spleen. She now needs to go back into the operating room to have the actual kidney removed. You can read more about it here.
It seems impossible that something like this can happen, and yet here it is. How can a doctor remove the wrong organ? It’s not like a spleen and a kidney look similar, or that the procedures are similar.
What Allowed this Medical Error to Happen?
Those that are not familiar with advanced root cause analysis immediately jump on the “It’s a bad doctor; remove his license!!” bandwagon. However, just thinking about it for a few minutes, it’s very likely that there are LOTS of causal factors here that allowed this to happen. I’ll list a few possible Causal Factors, and then I’d like YOU to add your own.
- Doctor had no previous knowledge of the patient’s history
- The paperwork did not identify the correct organ
- The wrong patient was operated on
- Various staff members did not verify the correct patient
I’ll let you continue to add your own possibilities in the comments section.
The point is, that we need to do a deep root cause analysis on this problem. You’ll note from the article that the most likely outcome of the impending lawsuit is that they will settle out of court. What do you think will be the results of the settlement? Will there be an impartial RCA completed, or will everyone be satisfied with just blaming the doctor?
It is critical in situations like this that a human performance-based root cause analysis be performed. We aren’t trying to affix blame, we want to understand how really smart, well-trained doctors, nurses, and hospital staff allow problems like this to occur. Fixing the root causes should be the focus.
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