In healthcare we talk about never events. Things such as surgeries done on the wrong side of a body, or the wrong body part, or even the wrong organ. These are horrible mistakes that we say should never happen. Yet, this article reminds us that these things keep happening (If you can’t see the New York. Magazine, you can read a news report on the incident here). The case highlighted in this article in one in which a surgeon removes a patient’s liver rather than the diseased spleen that needed to come out. Worse, the article goes on to suggest that the surgical team were not honest about what happened, though this case is still under investigation. The author rightly notes that the case is horrific, but sadly not unheard of. On the heels of this report, there is another medical mishap described here. Though this one is different in that this may have occurred at a site that should not have been doing procedures on patients. But it does make the point that both reputable and the less reputable institutions can lead to terrible outcomes.
I have discussed a variety of medical errors on this website, including events that lead up to my father’s cardiac arrest.
For those in the business of patient safety (both professionally and personally), we know all too well that these is not an isolated events. The question that continues to vex patients and providers, is why do “never events” keep happening?
We don’t know exactly how often these happen, because hospitals report them on a voluntary basis. So we learn about them through these voluntary programs, or when families come forward or seek litigation. Whatever we think we know about how often this happens, it is probably worse than we think. So…what now?
One of the challenges in trying to improve patient safety is overcoming the idea that all of us are fallible humans. I don’t think that the above cases are the result of people that did not care about their patients. I am reasonably confident that the doctors caring for my father wanted good things for him. Yet, in all of these cases. terrible things happened. Yet, if we want things to be different these physicians and others need to begin to believe, really believe, that they are fallible humans and start taking the necessary steps to create the fault tolerant systems that will help build the systems needed to help keep our patients safe.