May 14, 2009 | Dave Janney

Surgeon Allegedly Operates on Wrong Part of Mouth

Here is the story:

http://news.yahoo.com/s/ap/20090513/ap_on_fe_st/odd_wrong_side_surgery

Rarely does something like this make the national news, but it happens more than you might think.  Why?  Doctors and Nurses are human, and they make mistakes the same ways and for the same reasons as machinists, factory workers, forklift drivers, pilots, you, and me.  The question is, does the organization have the management systems and best practices in place to stop or minimize human error?  Does the organization apply the knowledge they have effectively or do they seek outside knowledge to help them?  

I’ve asked these questions for a reason; because human performance, best practices, and using knowledge are what the TapRooT® system is all about. Humans only work within the system we (management) provide and we owe it to them to develop and implement a system that works and to fix problems when we find them (or they find us!)

Attend a TapRooT® course today – here is the schedule:

http://www.taproot.com/courses.php

By the way, if you are reading this and are a Healthcare professional, you should join us for the Eliminating Hospital Sentinel Events track at the 2009 TapRooT® summit on October 7-9.  In addition to the summit, we have a two day pre-summit course TapRooT® and FMEA for Your Healthcare Root Cause Analysis.

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