Talk about not learning from your mistakes. There are so many simple ways of error proofing surgery, including having procedures in place to confirm the right patient is on the table and that the right surgery is about to take place.
You’d think after ONE mistake, the surgeon would take every precaution in the future, namely error proofing (yes, many of the processes involved aren’t just the doctor’s responsibility).
You’d think after TWO mistakes, the medical board would realize this is not “common cause” from the system (anyone can make one mistake, bad doctors make two).
At least the doctor was finally suspended after THREE similar mistakes. Yikes.
Whether you are in a factory or a hospital, there are many errors that are likely occur regardless of who the person is, the problems are systemic in nature. But, at some point, you find a person who is making more errors than the statistical norm… lean teaches us to look at the system to prevent errors and to not place blame. But, at what point DO you place blame?
Subscribe via RSS | Lean Blog Main Page | Podcast | Twitter @leanblog
LeanBlog on Facebook
"Move to Healthcare" Network
Lean Blog YouTube Channel