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Error Human

Here's an example of a significant mistake.  I'm not sure that just chalking it up to "human error" is good enough.


humanerror.gif (5450 bytes)

operates on
wrong hip

      WASHINGTON -- A surgeon replaced the wrong hip on a patient at Washington Hospital Center last week, prompting officials there to launch an investigation and apologize.
     Hospital officials Friday declined to identify the orthopedic surgeon who committed the error, but they said the hospital would pay the cost of Tuesday's procedure and any future operations.
      The patient remained in the hospital Friday, according to spokeswoman Lisa Wyatt, and is still in the doctor's care.
      The same doctor may perform the operation on the other hip later, she said.
     "The physician realized it at the end of the procedure and immediately acknowledged it, talked to the family and told the family what had occurred," Wyatt said.  "I don't know how he realized it.  It was human error.  I would say the doctor feels very, very badly.

-- The Washington Post

As scary as it is to contemplate that such an obvious case of medical malpractice could occur, it's the last paragraph of this article that hilariouses me.

Where she says, "I don't know how he realized it," the spokeswoman is telling us that she is altogether stumped as to how the surgeon might have figured out he was operating on the wrong hip.  Apparently she is just flabbergasted, and maybe even a little impressed, that he could ever have noticed at all.

Also, I doubt she means what she said, that the doctor "feels very, very badly."  If he's unhappy about his inexcusable mistake, then he feels bad, not badly.  If he feels badly it means his fingers are insensitive to touch or that he interprets cold as heat or some such thing, i.e., that when he tries to feel, he doesn't do it well.  It's bad enough that he's incompetent, but it would certainly be even worse if, as a surgeon, he really does feel badly.


Here are some more examples of human error:


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From the New York Daily News as printed in The Kansas City Star on February 28, 2001.

Brain surgery was done on wrong side, reports say

     NEW YORK -- The state Health Department and Long Island College Hospital are investigating allegations that surgery was performed on the wrong side of a patient's brain.
     Rene Kotzen, 44, and Mike Chou, 37, were suspended by the hospital Wednesday, one day after an operation on Kevin Walsh.
     Walsh, 41, was taken to the hospital's emergency room after a seizure.  Doctors there discovered a potentially lethal blood clot in his brain.
     The CT scan showed the the clot in the right side of the brain, but the surgery was initially performed on the left side, reports said.   Investigators were looking into whether the CT scan was backwards when placed on the viewing screen.
     Once the mistake was discovered, the left side was closed and surgery was performed on the right side, reports said.
     A hospital spokeswoman declined Monday to discuss specifics of the case because of ongoing investigations.
     Walsh was recovering at the hospital and was in stable condition.


Oh, and here's a tip.


This one's from The KC Star of April 25, 2001.  See, I told you.
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     Craig DuMond, a physician, was dismissed from practice at a Saranac Lake, N.Y., medical facility in March after operating on the wrong knee of a patient.
     Five years earlier DuMond had operated on a patient's wrong hip, so the medical center then initiated a safety procedure requiring the staff to write "yes" on the correct body part for surgery.
     Because DuMond operated this time on a part that did not contain the word "yes," the medical center now requires the staff to write "no" on the body parts that will not be operated on.


Now, here are two in one day!  Both are from the AP as published in The Kansas City Star of January 17, 2002.  Let me summarize each headline.
twosurgeries.htm (9,554 bytes) 04112003

Error results in surgery
on wrong side of head

In Providence, Rhode Island, a surgical team drilled two holes through the left side of a patient's skull only to discover it was the right side that needed surgery.  A CAT scan had been placed on an X-ray viewing box backwards.


Hospital mix-up blamed
for deaths of two women

In New Haven, Connecticut, on January 11th a woman died during heart surgery because someone plugged her oxygen line into the receptacle for anesthetic gas.  Four days later another woman died during the same type of procedure and for the same reason.

The last paragraph reads as follows:

"Officials would not identify the employees involved and said they do not expect to take any disciplinary action."


And here's more medical malpractice.

And here's yet more.


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