Operating on the wrong body part
This kind of article is published far too often, but this statistic is alarming:
“Doctors operating on the wrong body part have been a rare but persistent problem. In Florida last year it happened 52 times, according to the Agency for Health Care Administration.”
It's discouraging how some basic error-proofing and improved processes could have prevented all of these mistakes. There's really no excuse. That's why many health advocates are encouraging patients to write “NO!” in magic marker on the “wrong limb.” This is obviously a systemic problem, one that has to be accounted for with better methods than to tell doctors to “be careful.”
There are some corrective action processes in place, but hopefully they are using the “5 Whys” method to get to a true root cause solution. It would be nice if hospitals could proactively address avoidable problems rather than just reacting to every problem that occurs.
Also from the article:
In the case of the burned baby, the state Agency for Health Care Administration cited the hospital for the mistake and required it to submit a correction plan explaining what the hospital had done to avoid a similar mistake. In St. Mary's correction plan, submitted in March, the hospital said it had retrained its nurses and eliminated the practice of using warmed fluids in the neonatal intensive-care unit.
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