Friday, April 06, 2007
The mistake resulted from a series of missteps along the way, a classic pattern long recognized by safety experts. Errors, they say, are seldom due to a single doctor's or nurse's incompetence or negligence.
By its own guidelines and those of national hospital regulators, the VA hospital was required to obtain informed consent from the patient for the surgery, mark the operation site and take a "timeout" in the operating room to double-check that doctors were targeting the correct site, doing the correct procedure and operating on the correct patient.
According to Houghton's medical records, something appears to have gone awry at all three of these steps.
The consent form, prepared the day of surgery, stated that the right testicle was to be removed and a left vasectomy performed, when it should have said the opposite. The records do not say who prepared the form.
Both Leppert and Houghton signed it, Houghton said. Houghton did not have his glasses so could not read it, his wife recalled.
The surgeon said, " 'This is what we talked about before. Just sign here and here,' " Houghton said. "I didn't actually read it."
Although Houghton's experience serves as an object lesson on reading consent forms carefully, even a thorough examination won't necessarily catch errors, said Fran Griffin, project director at the nonprofit Institute for Healthcare Improvement in Cambridge, Mass.
"You see what you expect, not what is actually there," she said. "That's why the consent, while it's an important step, by itself will never be sufficient."
The next step — marking the site with a surgical pen — is supposed to take place before sedation, so the patient can participate.
Houghton said he was asked to identify the surgical site and pointed to his left testicle, but both he and his wife said no one marked it. Houghton's records don't mention a mark.
Finally, the medical records show that a timeout was called, but it's unclear whether medical personnel consulted any document besides the erroneous consent form.
Left and right, right and left. It's an easy mistake to make, whether you are documenting it in writing or clicking a drop-down menu, and once the wrong side is tagged, it just cascades down the chain.
And remember, the VA system is supposed to be a model of electronic health record perfection.
posted by Sydney on 4/06/2007 07:43:00 AM 1 comments
Never waste time with just the press release. They are written by innumerate hacks who are paid to push the favored slant. They probably didn't notice or comprehend their confusing selection of numbers.