Doctor Suspended For THIRD Wrong Surgery

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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 is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus. His latest book has been released as an "in-progress" book, titled Measures of Success.

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