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(Daily Mail)   Trainee surgeons: Oops, when we were inside you we grabbed the wrong organ. Our bad   (dailymail.co.uk) divider line 71
    More: Asinine, Hospital in Romford, General Medical Council, Romford, organ failure, multiple organ failure, surgeons removed, teaching assistant  
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8423 clicks; posted to Main » on 10 Jun 2013 at 1:41 PM (1 year ago)   |  Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



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2013-06-10 12:01:52 PM
Clean your pipes, ma'am?
 
2013-06-10 12:25:34 PM
wp.patheos.com.s3.amazonaws.com

And we'll take this liver, too, while we're at it.
 
2013-06-10 12:52:06 PM
Um.

Wow. Okay.

Let me guess. First year surgical residents?

The  unsupervised part of the article made me cringe. WTF, man.

On the other hand, this is the Daily Fail.
 
2013-06-10 01:03:27 PM
In Turk's defense, JD was doing his awesome Dr. Cox impression.
 
2013-06-10 01:42:41 PM
I believe the technical term is "medical misadventure".
 
2013-06-10 01:45:46 PM
i wish someone grabbed my "organ".
 
2013-06-10 01:50:33 PM
That's what she said?
 
2013-06-10 01:50:47 PM

rickythepenguin: i wish someone grabbed my "organ".


That's how you end up heavily pregnant.
 
2013-06-10 01:51:01 PM

hardinparamedic: Um.

Wow. Okay.

Let me guess. First year surgical residents?

The  unsupervised part of the article made me cringe. WTF, man.

On the other hand, this is the Daily Fail.


I'm more partial to it being the "Daily Fail." I've seen (minor) trauma surgeries being held up with the surgical team  (scrub tech, senior resident (4-5th year resident), intern (1st year resident)) scrubbed and ready to open because the attending wasn't physically present in the OR (the attending doesn't have to be scrubbed... just present).

Additionally, the story doesn't really make sense. The appendix is attached to the large intestine where the small intestine meets it ("cecum"). That's a lot of landmarks to use to find it that isn't in any way connected to the ovaries. Next, assuming they opened with out an attending ("consultant" in Brit speak) present, when they couldn't find it I have to imagine that they called the attending. I can't believe that the attending said, "Welp, just do your best. Carry on" and didn't scrub in to see if he could help.

Finally, there's the problem that the appendix doesn't look anything like an ovary.
 
2013-06-10 01:51:36 PM
Like a surgeon, cutting for the very first time!

Seriously where the fark was a supervising surgeon?
 
2013-06-10 01:53:50 PM

rickythepenguin: i wish someone grabbed my "organ".


While "inside you"?
 
2013-06-10 01:54:19 PM
farm3.static.flickr.com
 
2013-06-10 01:56:44 PM
She won't get ova it.
 
2013-06-10 01:58:49 PM
static.tvfanatic.com
 
2013-06-10 01:59:28 PM

davin: rickythepenguin: i wish someone grabbed my "organ".

That's how you end up heavily pregnant.


Just hope that you dont end up in the UK
 
2013-06-10 02:00:40 PM

JPINFV: .

Finally, there's the problem that the appendix doesn't look anything like an ovary.


What part of the word "screw-up" do you not understand? If they had behaved in a rational and reasonable manner, there would not have been a screw-up.

I outta know because I had a perfectly healthy organ removed mistakenly. Unfortunately, I was ten years old and my parents did not do squat about it.
 
2013-06-10 02:02:42 PM

uncleacid: She won't get ova it.


They are probably hysterectomy it.
 
2013-06-10 02:03:49 PM

rickythepenguin: i wish someone grabbed my "organ".


Theon Grayjoy once said that...
 
2013-06-10 02:05:10 PM
Was somebody a little too caught up in this game again?
 
2013-06-10 02:06:24 PM

worlddan: JPINFV: .

Finally, there's the problem that the appendix doesn't look anything like an ovary.

What part of the word "screw-up" do you not understand? If they had behaved in a rational and reasonable manner, there would not have been a screw-up.

I outta know because I had a perfectly healthy organ removed mistakenly. Unfortunately, I was ten years old and my parents did not do squat about it.


Well, it really depends on the "screw up." When you say "healthy organ," was it a misdiagnosis (we thought you had appendicitis, but when we removed it it was normal. This is actually the case about 10% of the time), they removed a different organ (like this case, swing for the appendix, hit an ovary), or was it a wrong side surgery (We want to take out your right kidney, but accidentally took out the left)?
 
2013-06-10 02:11:13 PM
It's okay, everybody. It's government-run medicine, so the doctors won't have to worry about silly things like "consequences".
 
2013-06-10 02:11:19 PM
my brain?  my brain?  that's my 2nd favorite organ

admin.purplerevolver.com
 
2013-06-10 02:17:16 PM
"In Britain, the government itself runs the hospitals and employs the doctors. We've all heard scare stories about how that works in practice; these stories are false." --Paul Krugman, Aug. 17, 2009
 
2013-06-10 02:18:03 PM
ts4.mm.bing.net

"Time to do what doctor's do best."

/obscure?
 
2013-06-10 02:19:25 PM

politech: [ts4.mm.bing.net image 325x247]

"Time to do what doctor's do best."

/obscure?


Not even a little...unfortunately.
 
2013-06-10 02:21:50 PM

Blues_X: [wp.patheos.com.s3.amazonaws.com image 640x354]

And we'll take this liver, too, while we're at it.


static.guim.co.uk

"That's our job."

/hated the movie
 
2013-06-10 02:24:25 PM
This occurred a year and a half ago. She died from the appendix being left in, not from the ovary being taken out.
 
2013-06-10 02:27:30 PM

nytmare: This occurred a year and a half ago. She died from the appendix being left in, not from the ovary being taken out.


So that makes it OK?
 
2013-06-10 02:29:33 PM

worlddan: I outta know because I had a perfectly healthy organ removed mistakenly.


4.bp.blogspot.com
 
2013-06-10 02:30:22 PM
Terrible. Gonna happen from time to time but jeez. Ugh.
 
2013-06-10 02:30:50 PM

JohnAnnArbor: "In Britain, the government itself runs the hospitals and employs the doctors. We've all heard scare stories about how that works in practice; these stories are false." --Paul Krugman, Aug. 17, 2009


And it's still false. When the error rate there jumps significantly higher than the error rate here, in the most expensive healthcare system on the planet, then you can trot out that implied strawman as if it has actual meaning. For every "scare story" regarding misdiagnosis or mistreatment in the UK, you'll find at  least one here, too.

Until then, though, don't bother.
 
2013-06-10 02:31:46 PM
Maria De Jesus
Adelino De Jesus
Dr Babatunde Coker
Coroner Chinyere Inyama
daughter Catarina, 10
son Pedro, 16


Does England have any English left?

by Anna Hodgekiss
Averil Dongworth, chief executive of the Barking, Havering and Redbridge Hospital Trust, admitted liability and apologised to the family in a letter they received on Saturday


Oh ok, the women reporting and apologizing for this story.
 
2013-06-10 02:36:27 PM

FARK rebel soldier: Maria De Jesus
Adelino De Jesus
Dr Babatunde Coker
Coroner Chinyere Inyama
daughter Catarina, 10
son Pedro, 16

Does England have any English left?

by Anna Hodgekiss
Averil Dongworth, chief executive of the Barking, Havering and Redbridge Hospital Trust, admitted liability and apologised to the family in a letter they received on Saturday

Oh ok, the women reporting and apologizing for this story.


o_O
 
2013-06-10 02:40:35 PM

FormlessOne: And it's still false. When the error rate there jumps significantly higher than the error rate here, in the most expensive healthcare system on the planet, then you can trot out that implied strawman as if it has actual meaning. For every "scare story" regarding misdiagnosis or mistreatment in the UK, you'll find at  least one here, too.

Until then, though, don't bother.


The problem that people refuse to address, however, is that medical errors are not always caused by lack of knowledge, lack of attentiveness, or lack of care. Many times, it's a chain of errors which leads to one gigantic, patient affecting error in the end.

The Institute of Medicine pointed this out years ago, in 1999.

Everyone will make a drug error or medical error at some point in their careers, because they are human. Thankfully, most errors will be caught before they cause harm. Because that's what human beings do. The thing that sets people up for failure and a repeat of the same is when the blame is exclusively placed on a person and nothing is done to correct the procedures and situation which led up to that error.

Example: Stock tech placing a bag of Lidocaine Premix, which looks almost exactly like Normal Saline, in the same bin as the NS on an Ambulance. During a critical trauma, Paramedic hangs the premix by accident and gives a bolus of it. 

Example 2: Experienced Pediatrics Nurse gives a form of Penicillin only meant for IM use through IV, and kills a neonate through a drug emboli in the lungs. The nurse was charged with manslaughter, and during the trial it was revealed that the bottles had been manufactured as looking the same as a Penicillin G bottle, and were next to impossible to differentiate easily, and had been stocked by pharmacy in the same location as the IV Penicillin vials.
 
2013-06-10 02:40:55 PM

nytmare: This occurred a year and a half ago. She died from the appendix being left in, not from the ovary being taken out.


And they didn't notice it wasn't the appendix after they removed it?

Unlikely.
 
2013-06-10 02:42:34 PM

FormlessOne: JohnAnnArbor: "In Britain, the government itself runs the hospitals and employs the doctors. We've all heard scare stories about how that works in practice; these stories are false." --Paul Krugman, Aug. 17, 2009

And it's still false. When the error rate there jumps significantly higher than the error rate here, in the most expensive healthcare system on the planet, then you can trot out that implied strawman as if it has actual meaning. For every "scare story" regarding misdiagnosis or mistreatment in the UK, you'll find at  least one here, too.

Until then, though, don't bother.


www.bfi.org.uk
 
2013-06-10 02:42:59 PM

mcreadyblue: nytmare: This occurred a year and a half ago. She died from the appendix being left in, not from the ovary being taken out.

And they didn't notice it wasn't the appendix after they removed it?

Unlikely.


You'd think once they looked at it they'd understand the gravidy of the situation.
 
2013-06-10 02:44:40 PM

hardinparamedic: FormlessOne: And it's still false. When the error rate there jumps significantly higher than the error rate here, in the most expensive healthcare system on the planet, then you can trot out that implied strawman as if it has actual meaning. For every "scare story" regarding misdiagnosis or mistreatment in the UK, you'll find at  least one here, too.

Until then, though, don't bother.

The problem that people refuse to address, however, is that medical errors are not always caused by lack of knowledge, lack of attentiveness, or lack of care. Many times, it's a chain of errors which leads to one gigantic, patient affecting error in the end.

The Institute of Medicine pointed this out years ago, in 1999.

Everyone will make a drug error or medical error at some point in their careers, because they are human. Thankfully, most errors will be caught before they cause harm. Because that's what human beings do. The thing that sets people up for failure and a repeat of the same is when the blame is exclusively placed on a person and nothing is done to correct the procedures and situation which led up to that error.

Example: Stock tech placing a bag of Lidocaine Premix, which looks almost exactly like Normal Saline, in the same bin as the NS on an Ambulance. During a critical trauma, Paramedic hangs the premix by accident and gives a bolus of it.

Example 2: Experienced Pediatrics Nurse gives a form of Penicillin only meant for IM use through IV, and kills a neonate through a drug emboli in the lungs. The nurse was charged with manslaughter, and during the trial it was revealed that the bottles had been manufactured as looking the same as a Penicillin G bottle, and were next to impossible to differentiate easily, and had been stocked by pharmacy in the same location as the IV Penicillin vials.



Accidents do happen.  We are human.  However, we must be careful not to mistake confusion with carelessness.  In both of the above cases, following SOP would have averted the outcomes.  Being tired, being confused is completely understandable.  But let's be clear on those two.  The providers did not read the labels.  That's a little bit different than rooting around in someone's innards.
 
2013-06-10 02:45:23 PM

mcreadyblue: And they didn't notice it wasn't the appendix after they removed it?

Unlikely.


Since we really don't know the whole story, for all we know she could have been scheduled for an oophrectomy rather than an appendectomy. Unless the appendix is ruptured, they're not going to realize anything is amiss unless they actively question the nurse and the patient.

Ironically, I know in the US each procedure is supposed to require both a time out, and a review of the chart and labs. Wonder if that happened here.

info.visiblebody.com
 
2013-06-10 02:47:09 PM

BafflerMeal: In both of the above cases, following SOP would have averted the outcomes.  Being tired, being confused is completely understandable.  But let's be clear on those two.  The providers did not read the labels.  That's a little bit different than rooting around in someone's innards.


Yeah. About that.

Both situations had to do with errors that occurred during high stress, critical situations in high acuity areas of care, where accidents are most likely to occur.
 
2013-06-10 02:51:58 PM
4.bp.blogspot.com
 
2013-06-10 02:56:01 PM
I've posted this repeatedly, but if I'm ever going to go under for an operation, I'm taking a sharpie to my body and pointing out, with arrows, x's, dotted lines, where the fark  the doctors need to working.
 
2013-06-10 02:58:07 PM

hammettman: I've posted this repeatedly, but if I'm ever going to go under for an operation, I'm taking a sharpie to my body and pointing out, with arrows, x's, dotted lines, where the fark  the doctors need to working.


And just for comic effect, that buzzer system from 'operation'..
 
2013-06-10 02:58:19 PM

hardinparamedic: BafflerMeal: In both of the above cases, following SOP would have averted the outcomes.  Being tired, being confused is completely understandable.  But let's be clear on those two.  The providers did not read the labels.  That's a little bit different than rooting around in someone's innards.

Yeah. About that.

Both situations had to do with errors that occurred during high stress, critical situations in high acuity areas of care, where accidents are most likely to occur.



I completely understand.  As someone with a great deal of experience with that myself, I know where accidents and oversights can occur.  But the context of said mistakes does not negate the reality, that SOP was bypassed for convenience in the worst case or by accident under stress in the best case.

I'm not being argumentative against human nature, but I am saying that I am a hard-arse educator and practitioner.
 
2013-06-10 02:58:25 PM

hammettman: I've posted this repeatedly, but if I'm ever going to go under for an operation, I'm taking a sharpie to my body and pointing out, with arrows, x's, dotted lines, where the fark  the doctors need to working.


The place I work at actually writes the procedure on the body area with a sharpie after they prep the site, and if it's on a limb, will write "DO NOT CUT" on the other limbs.
 
2013-06-10 03:00:21 PM
Couldn't tell without reading if the article was about the TSA or what happened at Band Camp in the marching Organ Monkey brigade.
 
2013-06-10 03:00:25 PM

BafflerMeal: I'm not being argumentative against human nature, but I am saying that I am a hard-arse educator and practitioner.


Which, both reports even pointed this out, is easy to do from the armchair of hindsight. The problem is that the environment for such practices and errors is fostered in systems which act reactively and punitively to errors, rather than proactively and work to reduce them through education and correction of engineering and equipment problems.
 
2013-06-10 03:03:01 PM

hammettman: I've posted this repeatedly, but if I'm ever going to go under for an operation, I'm taking a sharpie to my body and pointing out, with arrows, x's, dotted lines, where the fark  the doctors need to working.


Actually, you're not far off.  I have had the ACL in both my knees torn.  In pre-op, the nurse gave me a sharpie and told me to write "yes" on the busted knee and "no" on the good knee.   Worked out fine both times!
 
2013-06-10 03:08:48 PM

Flakeloaf: mcreadyblue: nytmare:

This occurred a year and a half ago. She died from the appendix being left in, not from the ovary being taken out.

And they didn't notice it wasn't the appendix after they removed it?

Unlikely.

You'd think once they looked at it they'd understand the gravidy of the situation.


G-R-O-A-N. Not only is that a bad pun, it's a bad pun: the word is "gravidity." Maybe you need more caffeine, sir and/or ma'am?1

Anyway. TFA said she was so pregnant they had to do it by feel, that parasite inside her took up a lot of space, but once they had the organ out they should have been able to say "Hey, that's not a bad appendix, that's an ovary! And a good one too! UH-OH.)" They would look different, wouldn't they?2

Obviously damage control would have been trying to find the appendix again, then afterward explain how she happened to be minus one ovary, point out that she only needs one (and maybe that it's one fewer that might get cancerous later), and beg her not to sue. I'd like to think I'd be so happy I haven't miscarried or died that I'd shrug off a missing ovary, but then I'm weird in a more manly way.3

So like WTF?

1 I always do: some days my jones is so bad I treat coffee like I used to treat cigarettes: the cue to needing another one is finishing this one.

2 I'd post photos of a healthy ovary and a bad appendix but that might be too graphic for Fark.

3 I have male reproductive organs instead. Really. But you'll probably want to take my word for it, okay? There's no need to be exacerbating anybody's complexes.
 
2013-06-10 03:10:00 PM
JPINFV:  Additionally, the story doesn't really make sense. The appendix is attached to the large intestine where the small intestine meets it ("cecum"). That's a lot of landmarks to use to find it that isn't in any way connected to the ovaries. Next, assuming they opened with out an attending ("consultant" in Brit speak) present, when they couldn't find it I have to imagine that they called the attending. I can't believe that the attending said, "Welp, just do your best. Carry on" and didn't scrub in to see if he could help.

Finally, there's the problem that the appendix doesn't look anything like an ovary.


That's what I thought as well.  The normal anatomy isn't remotely similar, and they should have been helped by the distended, inflamed looking thing hanging out on the GI tract.
 
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