The news this morning brings a report from Minnesota of a wrong-sided removal of a kidney. Horrible, we will all quickly agree. How did it happen, we ask? Wrong sided surgery reports continue to come to our attention despite the many checks and balances we have brought to our systems. Most famous of course is the "Time Out" just before incision (puncture, etc.) wherein all members of the team are to agree that the right patient at the right time is getting the right procedure performed upon the correct side. If the paperwork and the images and the relevant parties all agreed that the correct action was about to be undertaken, how could the wrong kidney be removed from this unfortunate patient? There are many reasons, we all know, and these have been well characterized.
In my humble opinion the major obstacle we still face in preventing any future tragedies of this kind is the persona of the surgeon. Ladies and Gentlemen: many of us persist as major SOBs in this age of emotional intelligence. We have yelled at enough people enough times so as to prevent the necessary "stop-the-line" mentality that all must embrace. In Pogo-esque fashion, we have met our enemy.
How many of us patrol our OR's to get a sense of the validity in our own institutions of our time-out processes?
No comments:
Post a Comment