Doctor Gives Public Mea Culpa After Surgical Mistake

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Dr. David Feldman, chief safety officer and vice chair of surgery at Maimonides Medical Center in Brooklyn, N.Y., is an advocate of safety guidelines and regimented protocols. Before each surgery, every person in his operating room introduces themselves. Doctors reiterate the patient's name and surgical site and quickly go over procedures again.

Before the patient leaves the room, doctors at Maimonides, among other things, wave a detector over the patient's body designed to spot any soft items like sponges or towels if they have been left in the patient after surgery. Pathology labels are double-checked to be sure the correct name is on the labels.

To Err Is Human?

But despite such cautionary practices, Feldman said he did not think surgery will soon be just right. "We as a society have an expectation of perfection, but it's unrealistic to think surgeries will be perfect," said Feldman. "Humans are not perfect beings, and there are always going to be mistakes."

Dr. Thor Sundt, professor of surgery at Mayo Clinic, agreed.

"These errors are unfortunately inevitable because of the complexity of the business we're in," said Sundt, another strong advocate of surgery guidelines. "The trick is error management. Everyone on the team must be mindfully engaged and empowered, so they can capture those errors and correct them."

Charles Perrow, professor emeritus of sociology at Yale University, wrote "Normal Accidents," a book that examines the complex systems that surround us. The more complex the system, Perrow says the more likely there will be errors.

"When you move from one person to two persons you get a 'crack' that something might fall into," Perrow said. "With a half a dozen people in the operating room the number of possible cracks increases exponentially. We always make mistakes and we hope that others will catch them before they do too much damage, but with increased specialization the others are less likely to catch our quite specialized mistake."

Sundt and his colleagues at Mayo Clinic, meanwhile, have taken safety guidelines one step further than the university protocol. Before every surgery, Sundt pauses to confirm the name of the patient, the procedure that is about to take place, antibiotics dosage and any special equipment that is needed in the operating room. In 2010, medical briefings were also made mandatory at Mayo Clinic. While a checklist is the same for every surgery, briefings change for different surgeries. The idea is to make everyone, including the patient, comfortable enough to speak up if necessary. Even when a nurse ends a shift, he or she must brief the new nurse on the specific operation at hand.

"Everyone, including patients, needs to be part of the team and be an active participant in the process," Sundt said.

Patients have been known to use permanent markers to write on their bodies to mark a surgery site. Feldman said patients should ask questions, reiterate the surgery to the doctor, go ahead and write on themselves to help map out their surgery -- and even make sure the surgeon has washed his or her hands.

"Some doctors might get annoyed to have a patient ask if they've washed their hands, but if that's the case maybe that patient shouldn't be seeing that doctor," said Feldman. "Doctors have to realize that encouraging patients to be involved and ask questions all helps with patient safety."

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