Oops, They operated on the wrong knee…

Did you see that some surgeons operated on the wrong knee of their patient last week? (Feb. 18, 2009, Providence) NECN said that “After the botched procedure, the hospital began requiring surgical staff to use permanent markers to mark where the doctor is supposed to operate.”   In a similar case at Beth Israel Deaconess 2 years ago, the patient’s leg was marked and they still operated on the wrong leg.

The Sr. VP of Health Care Quality at BIDMC said “that medical workers used a marker to correctly label the side of the patient that should have been operated on but that, somehow, the surgeon failed to notice the marking…   Perhaps most crucially, the team of medical workers hovering in the operating room neglected to conduct what’s known as a “time out” before the surgeon first placed his scalpel on the patient. Time outs are safety procedures that require the operating team to verbally call out, “Right patient, right procedure, right location.”

Now there’s a conversation that needed to happen.  Problem is, in health care, some critical conversation don’t happen, that result in serious mistake, like wrong-side surgeries.  There are people who’ve been studying this phenomenon, the authors of “Crucial Confrontations”.  They have found that problems arise when important conversations don’t happen, between doctors and nurses, nurses and nurses, doctors to doctors, etc. – because they’re afraid to confront colleagues who make a mistake or cut corners.  Even pharmacists are afraid to confront doctors who’ve been hostile in the past.  

The solution: teach people to engage in difficult, crucial conversations.  In situations where the stakes are high, like hospitals, communication skills are very important – as important as clinical skills.  There are those power issues again (see Handwashing post).  People need to learn what holds them back, they need tools that will help them have those conversations, and they need to experience what it feels like to engage those who have more political or organizational power.

The results: they’ve seen better patient outcomes when they have these conversations. You can read their fascinating research on SilenceKills.com.

One thought on “Oops, They operated on the wrong knee…

Add yours

  1. Love the blog Abby!

    I couldn’t agree with you more and love this example as the consequences of not asking the questions, difficult or not– or not taking the time because we are multi-tasking and need to get on to the next thing, are very palpable here. The challenge of getting Docs and Very Important People to believe they don’t just know it all is significant. Wondering what success you and others have had actually changing cultures to facilitate this.

    Jane A
    Arlington, MA

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