Operating on the wrong body part


    Serious errors by doctor, nurse reported at St. Mary's Medical Center

    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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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. Mark,

      I had shoulder surgery two years ago. I was quite worried about the risk of getting my left, not the painful right, shoulder worked on. And I was on the lookout for the mistake-proofing they’d use…or not.

      I was pleased.

      The nurse looked on the chart. She confirmed with me that the right shoulder was the one. And she then shaved the right shoulder and upper chest. Only.

      Then the Doctor came in, pre-op. He referred to the chart again. He reviewed which shoulder it was with me again. Then HE SIGNED MY SHOULDER! I chuckled with him about it and he said this was just the way to make sure they get it right every time.

      Thought you’d enjoy this.



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