Oops! Top Doctors Perform Surgery on the Wrong Patient! Outrageous Post Mortem Follows! (Part 1 of 2)Imagine you are in the hospital in the middle of a complex surgery. Specialists concentrate on their duties busily. The machine that goes beep is running confidently. Surgeons have put a tube into your leg that extends to your heart.
Then there is a whispered discussion followed by one of the surgeons poking his head over yours to say something to the effect of, "I'm sorry, but it appears that you are the wrong patient for this procedure."
This really happened. In fact, the more detail you uncover, the more fascinating the situation becomes, and it turns out that this health care case study relates directly to how you manage your projects.
How Could This Happen?
This inauspicious incident was described in a June 2002 issue of Annals of Internal Medicine, which you may have misplaced under that pile of reports on your desk. It included an analysis of what went wrong. The authors identified 17 separate events in the process where the mistake could have been identified and the problem avoided. Seventeen!
Jaw-Dropping: Three Events from the Report
· The patient was actually supposed to be discharged that day and was just about to leave when nurses talked her into the operation, believing she was just afraid. Nurses did not question orders to take the wrong woman to surgery.
· The patient's medical file did not contain critical patient history
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