Lessons From a Sad Error

I think many people have seen this sad story of a wrong-sided kidney removal in Minnesota. We all feel the pain for this poor patient. It is difficult for us non-physicians to understand how this happens, for the pathway to the error seems remarkably clear after the fact. But, we have to understand that the actual delivery of medical care contains multiple opportunities for mistakes, and even extremely competent and well meaning doctors and nurses can find themselves in shock afterwards when this kind of thing occurs.

Here are two emails I have received on the topic which both offer useful perspectives on the matter.

First, my buddy E-patient Dave writes:

I’ve caught a couple of errors on my radiology reports, and have had them corrected. Both VERY minor compared to this. Can there be any doubt that patients need to have access to their records, as PatientSite allows, and need to be aware of their need (and ability) to read them?

Second, from one of our senior surgeons to his colleagues:

As copied below, another high profile event, to remind us how easily error can occur. In this case the consent was wrong when done in the office, and it was the only document used to confirm sidedness at the time out. As you read the article, you will note this tragedy extends not only to the patient but to the entire team, as well as the institution.

I would remind you that we had our own "near miss" here at BIDMC, which was caught by the attending surgeon, and confirmed on reviewing the images. In our case, the patient had confirmed the wrong site to the nurses, residents and fellows involved, so patients are not infallible. To best avoid this we (multiple providers) must use multiple sources of information (including the patient, exam, imaging and documentation), and we must have all OR participants agree actively that the patient ID, procedure, side and site are correct. Also as highlighted by this case, the episode of surgical care and opportunity to err starts the first time we see the patient.

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