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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 18
    More: Asinine, Hospital in Romford, General Medical Council, Romford, organ failure, multiple organ failure, surgeons removed, teaching assistant  
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8417 clicks; posted to Main » on 10 Jun 2013 at 1:41 PM (44 weeks ago)   |  Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



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2013-06-10 01:51:01 PM
6 votes:

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 02:40:35 PM
2 votes:

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.
2013-06-11 09:41:52 AM
1 votes:
1. Removing an appendix from a patient with a heavily gravid uterus can be difficult even for an experienced surgeon.
2. Ovary/fallopian might resemble an Inflamed/ruptured appendix, especially to the inexperienced surgeon who can't see the thing in the first place.
3. Given that 1 and 2 are generally known in the medical community (or should be), absolutely not understandable or OK that the attending was not involved in the surgery itself, that the pathology report was not followed, that no one caught the continuing signs of appendicitis, etc.
4. Yikes.
2013-06-11 07:56:42 AM
1 votes:
...and neither surgeon wondered why a five month pregnant woman needed her ovary out so urgently. Not to mention they let her go home with the same symptoms that she was admitted with in the first place, probably worse than before, instead of keeping her there and maybe looking really hard at why she was still very ill.

Awful story.
2013-06-10 05:10:32 PM
1 votes:
BafflerMeal:

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.

  I get the newsletters from the Institute For Safe Medication Practices as part of my work (at an EHR vendor), and many of these errors are actually caused by unsafe or unclear labeling.  Two issues that come up quite a bit are
A) two drugs with very similar generic names but different dosing and schedule (such as the two chemo drugs "trastuzumab" and "ado-trastuzumab emtansine", or even closer ones like "prednisone" and "prednisolone")
B) The manufacturer using the same colors and labeling layout on two different strengths of the drug.  For example something like heparin vials with 100 units/ml and 10,000 units/ml both having a yellow label with very small print.

  Most of those issues get resolved through a combination of warnings going out to health care providers to check how things they have in stock are labeled, and then requests from IMSP and sometimes the FDA to manufacturer's to change the labelling.

 Now the real errors are the cases where a provider gets warnings and continued to ignore them and do the wrong thing.  There was a case about a year ago where a nurse got multiple warnings from their EHR system and the barcode scanner that the patient and medication didn't match what was in the system and yet manually overrode every warning and gave the drug to the wrong patient anyway.  I can't recall if the patient died or simply had an adverse reaction, but some people will continue to do the wrong thing no matter how obvious it is.

  In this case in the TFA, the really astounding part is that before her initial discharge, apparently no one read the pathology report from the surgery that would have told them it wasn't her appendix (and based on the timelines in the article it was available before the discharge).  Maybe they need a protocol that when the lab tech notices they were given the wrong organ, they actually call the surgeon directly.
2013-06-10 04:10:10 PM
1 votes:
I can't for the life of me figure out how someone would make this mistake.
2013-06-10 03:40:46 PM
1 votes:
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.


This is probably why the hospital has admitted fault and the GMC is investigating eight people, including a Senior Consultant (presumably the Surgeon who should have been running the show).

It sounds like this was such a massive fark up that it's not even worth attempting a defense.
2013-06-10 03:08:48 PM
1 votes:

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 02:51:58 PM
1 votes:
4.bp.blogspot.com
2013-06-10 02:47:09 PM
1 votes:

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 02:21:50 PM
1 votes:

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 02:18:03 PM
1 votes:
ts4.mm.bing.net

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

/obscure?
2013-06-10 02:11:19 PM
1 votes:
my brain?  my brain?  that's my 2nd favorite organ

admin.purplerevolver.com
2013-06-10 02:11:13 PM
1 votes:
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 02:00:40 PM
1 votes:

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 01:54:19 PM
1 votes:
farm3.static.flickr.com
2013-06-10 01:03:27 PM
1 votes:
In Turk's defense, JD was doing his awesome Dr. Cox impression.
2013-06-10 12:52:06 PM
1 votes:
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.
 
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