Learning from Mistakes: An Operating Room Case Study on the Consequences of Ignoring Small Errors

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This article caught my eye today, and it's a change of pace to think about and write about mistakes other than my own (and I made more today — but healthcare mistakes are more important).

Penn Medicine hospital cited over wrong-site surgery

It's a mistake to perform surgery on the wrong leg. Not an “unintended mistake” (which is redundant). All mistakes are unintentional. Intentional harm could be called sabotage or assault.

Pennsylvania health officials have cited Lancaster (Pa.) General Hospital for several safety issues in recent months, including a wrong-site surgery, Penn Live reported Feb. 23.

There was an “anonymous complaint.” That seems like evidence of an apparent lack of psychological safety, the “anonymous complaint.” Why did it have to come to that?

State reports cited by the publication show a surgical team at the hospital performed reconstruction surgery on a patient's wrong ankle in December.

Clearly a mistake. What happened? Let's look at some reported facts and what's admittedly some conjecture and educated guesses on my part.

A staff member marked the correct ankle prior to surgery…

That's good.

but did not place the mark within two inches of the surgical site, as per hospital policy.

That's bad. But that's starting to really sound like a culture problem. Did people not feel safe to speak up about this bad practice? We'd have to assume this wasn't the first time somebody didn't properly mark the site.

Then what happened?

Another employee placed a tourniquet on the wrong leg, and the surgical team realized the error shortly after the operation.

This mistake was a team effort. And I'm NOT suggesting that “naming, blaming, and shaming” a group of team would be better than blaming just one.


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Instead of “who screwed up?” we should ask, “how could that have happened?”

Did the supposed so-called “Universal Protocol,” including the “surgical time out” take place? If not, why? And if not, was this the first time that wasn't done? Probably not. Whose fault is that?

Prompted by Ann Richardson's post on LinkedIn, I wrote this:

Some people, when they read that article, will ask, “Who should be punished?”

A better question is, “What could have prevented that?” And maybe “Whose fault is it that the problem wasn't prevented?”

Unless that was the first time that surgery was ever done, I'll propose there's a high likelihood that one or more of these things happened previously:

  1. Surgeon didn't mark close enough to the surgical site (bad practice)
  2. Somebody almost put the tourniquet on the wrong leg, but noticed and didn't do it (near miss)
  3. Somebody did put the tourniquet on the wrong leg, but caught it and then put it on the correct leg (near miss)

Any or each of those should have been an opportunity to learn and improve, which could have prevented the ensuing patient harm.

If people aren't speaking up and reporting bad practices and near misses, that's a culture problem. Whose fault is that? Not the front-line staff. Look higher in the org. chart. Don't blame the employees for not speaking up when they might feel like:

  1. It's unsafe to speak up because they or somebody else will get in trouble
  2. It's not worth the effort because nothing gets fixed
  3. They don't have the time to report the problem (and maybe see #2 again)

If leaders aren't actively encouraging people to speak up about bad practices and near misses, that's a leadership problem. If they're not rewarding the people who do speak up, that's a leadership problem.

If they're not turning incident reports into effective problem solving, improvement, and prevention, that's a culture problem… a leadership problem.

For all of the loose talk of “accountability” (which usually means punishment), why is it apparently only the front-line employees who face life-altering punishments then?

A $40,000 fine is not life-altering to the hospital or its leadership team.

The hospital spokesperson made the predictable, tired, and seemingly inaccurate statement like they always make:

“Ensuring the safety of all patients is our top priority.”

As the late Paul O'Neill might have asked, “How do we know that is really true?”

As Ann asked, why do these things still happen in 2023?

Punishing mistakes (or threatening to punish them) doesn't lead to fewer mistakes. It certainly doesn't get us close to zero mistakes and zero harm.

If punishing mistakes led to fewer mistakes, that strategy would have worked by now.

It's time for a new approach. I'm not saying I have all the answers, but my upcoming book The Mistakes That Make Us explores this and shares what some organizations are doing to prove that a focus on learning and improvement (instead of punishment) is actually not just “fair and just” — it's also more effective.


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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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