Causes of mistakes

6, February 2017

Surgery on the wrong side!

surgery-on-wrong-brainThis is a ridiculous medical blunder.

Yet, your biggest blunder could be to blame the doctor for his carelessness.

Pause for a moment to think this accident through.

Firstly right and left can be easily mistaken – depending on the point of reference.  Not to mention that shape of skulls may not be entirely similar from one person to another.  Most likely, the patient is unconscious during and throughout surgery.  In the operating theatre, the standard operating procedure is to place a sanitised cloth over the patient except for a reasonable size hole showing the location for the incision to be done.

Of course, the whole preparation procedure for surgery would be carried out by a team of Operation Theatre nurses. If the cloth does not have proper marking, it could be easily disoriented.  Those who do ironing of clothing will be familiar with how easily it is to flip a garment upside down. Not to mention that certain clothing designs are wearable from both sides!

Then of course, the surgeon concerned should have checked before making the incision, which under normal circumstances, would be a normal course of action.

The fact of this case is that the surgery was done on the wrong side of the brain.

In life, as in work, we have always been quick to point out the party at fault.  This may or may not be correct.

Slide72Inside the 12-steps of Problem Solving posted by me in the previous posts are areas which can help us not to make mistakes. The intent is to move away from single cause for problems until we have satisfactorily ruled out the other unlikely causes.

If we take the trouble to examine them, almost all problems have more than one cause’

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