Another wrong-site surgery case occurred in Iowa. This one involved a knee replacement. According to the Iowa Board of Medicine’s press release the patient intended a double knee replacement, but one at a time with time in between for recovery. The first knee was to be the right knee followed by the left knee. Apparently the first surgery began, but on the wrong knee, requiring the surgery to be stopped, the patient’s family consulted and having to make a decision about how to proceed. In this instance the family made the decision to proceed with a double knee surgery on the same day.
We have discussed time-out procedures before surgery and how these are comparable to a pilot’s pre-flight procedures. [Intro to Flight and Preflight Procedures]
Student pilot training recognizes the ten most common errors in preflight procedures. Here they are.
1. Failure to use or the improper use of checklist.
2. Hazards which may result from allowing distractions to interrupt a visual inspection.
3. Inability to recognize discrepancies.
4. Failure to assure servicing with the proper fuel and oil.
5. Failure to place and secure essential materials and equipment for easy access during flight.
6. Failure to maintain accurate records essential to the progress of the flight.
7. Improper adjustment of equipment and controls.
8. Excessively high RPM after starting.
9. Improper preheat of the engine during severe cold weather conditions.
- Failure to assure proper clearance of the propeller.
The same applies to pre-surgical team review of the case before the first incision is made. In this instance the mistake is not just the surgeons. The mistake is the entire surgical teams. Although life is not a box of chocolates, having the wrong knee operated on is not “just a mistake”, as I’ve heard in many of these cases. And no, the surgeon and the hospital should not be paid for their mistakes. (i.e., betting paid for the first or the second surgery.)
The surgical team’s mistakes began long before the surgery started.
- Did they not read the chart before the surgery began?
- Or was the chart wrong?
- Did no one ask the patient which knee would be operated on that day?
- Did no one mark the extremity before the patient was sedated?
- Why didn’t someone on the surgical team point out the obvious mistake?
- Why did the surgical team allow the doctor to stand on the wrong side of the patient?
- A total failure of what is called 'active communication'.
In all of this was first assumed the entire team knew what we learned in kindergarten, the difference between the righty and lefty.
Assume nothing, because when you assume you make an ass out of you and me.