The right timing of safety protocols…

In Patient Safety on December 26, 2010 at 5:48 pm

Boston hospital made 3 spine operation errors

On Friday December 24, 2010, 10:12 am EST
BOSTON (AP) — A major Boston teaching hospital has been cited by federal and state health inspectors after doctors operated on the wrong location on three spine surgery patients.
All three unconnected errors happened since September.
Dr. Kenneth Sands is the senior vice president of health care quality at Beth Israel Deaconess Medical Center. He tells The Boston Globe the surgeons apparently miscounted the patients’ vertebrae and operated directly above or below where they were supposed to.
Two operations were conducted by the same surgeon. The hospital did not release names. The hospital has procedures in place to avoid errors, and those procedures have been improved.
Sands says none of the patients suffered harmful effects as a result of the mistaken surgery. But a lawyer for one says the woman has experienced problems. Information from: The Boston Globe,

Safetydog Comment: When two different surgeons and their teams (and one twice) make an error it is imperative to look at the team process. I think we have to look at the timing of checklists. It seems time out at the onset of an OR procedure is not enough. A time out needs to be repeated before every irreversible cut.
Human Factors can be used to determine when in a process some kind of alert has to occur when that should be a human alert or a technology produced alert. Rather than just copy best practices, hospitals need to review their current practices, reduce unnecessary steps and then identify areas in the process where a reminder or alert should take place. Timing is key. There are always points in a process after which there is no resiliency.

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