Relying on Memory Leads to Errors


Patient Safety Blog – Telling Our Stories

Here is an unfortunate story about a surgeon operating on the wrong side of an 86 year-old man, who died sooner after. There's no clear cause-and-effect between that error and death:

The surgeon didn't confirm his memory by checking the CT scan, health inspectors found. He wrote down the wrong side on the form, and then cut open the wrong side. When he realized his error, he operated on the correct side.

The patient 86-died Saturday, and the medical examiner's office is still trying to determine whether the surgical error contributed to his death.

Procedures were clearly not followed, even given that this was an emergency surgery.

The hospital's chief quality officer said that the staff's sense of urgency about caring for the patient had superseded the rules.

Of course, as the quality officer added, emergencies are “exactly where policies and procedures need to be as tight as possible.”

Exactly. Policies and procedures are in place to protect patients and I can't imagine it would have taken much longer for things to be done properly.

The book “To Err Is Human: Building a Safer Health System“, about 7 years old at this point, pointed out that relying on memory was a major cause of errors. Standardized Work was not followed in this case — how do we prevent that error from happening again? There were many people involved in this error, I'm not trying to point fingers just at the surgeon. We need to ask “why?” Why did this happen? Follow through the “5 Whys.” If a response is “it was an emergency and we were busy,” what is the “why?” for that? Was staffing too low? Not enough training? Not enough leadership oversight of the Standardized Work?

You might wonder if the recommended “time out” process was in place, a recommended practice where any participant can “pull the andon cord” to “stop the line” (stopping the procedure, really).

Cooper said that she believed someone in the operating room had questioned whether the correct side was being cut, but the surgeon was confident he was right.

There's yet another element of Standardized Work that was not followed. Overconfidence and over-reliance on memory sure seem to be contributing factors.

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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.


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