Doctor Suspended For THIRD Wrong Surgery

theledger.com

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?

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Mark Graban
Mark Graban

Mark Graban helps leaders build workplaces where people speak up and improvement sticks, through Lean management, psychological safety, and better use of metrics. He is a keynote speaker, advisor, and host of the Lean Blog Interviews and My Favorite Mistake podcasts.

He is the author of The Mistakes That Make Us, Measures of Success, Lean Hospitals, and Healthcare Kaizen, and a three-time recipient of the Shingo Publication Award. His next book is The Silence Tax.

Mark is also a Senior Advisor to KaiNexus. Get his free ebooks.

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