It should never happen ... but it does
One of the phrases currently in vogue in medicine is "never events," which refers to things, particularly mistakes, that are so preventable that they should never happen. Insurance companies are even threatening to refuse to reimburse hospitals for costs incurred when a "never event" occurs.
Here's a Boston Globe blog post about one such "never event" that took place this week at Beth Israel Deaconess Medical Center there. The nature of the procedure hasn't been disclosed, but in general what happened was that the wrong side of a patient was operated on. Fortunately, the patient is recovering and will suffer no lasting damage.
The Health Care Blog republishes a memo sent to hospital staff that is remarkable for its openness. It says two important things: 1) There are procedures in place to prevent this type of mistake from happening, and 2) in this case those procedures were not followed.
Medical professionals and patients alike can learn from this. The pros are reminded that these procedures exist for a reason and must be followed without exception. Patients are reminded that they need to ask questions of those who care for them to ensure that "right patient, right procedure, right side" is where the operation goes. (When I underwent shoulder surgery several years ago, the surgeon put a big X on the appropriate shoulder before surgery. I asked if that was to make sure the wrong shoulder didn't get operated on, and his response was something along the lines of, "You're darned right."
Some patients have taken it upon themselves to mark or label the wrong side with phrases like "Other side, please" or "Not this one." Some do it as a joke, but as this incident shows, it ain't funny. If the patient in question had been, say, having a cancerous kidney removed, he'd be in serious trouble.
I should stress that these events are very rare. But the potential consequences could be deadly. Procedures are in place for a reason. Docs, nurses and patients need to know about them and make sure they're followed.
