Medical Errors

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            I am going to talk about a medical error that can happen a lot.  It is when a surgeon does the wrong surgery on the wrong site.  I will talk about how this can happen and also why it happens.  I will determine if the error was result of an action or inaction and also if the error was skilled based slips or lapses it could be any kind of mistake.  I will also mention if FMEA process is analyzed and the error be recommended for improvement strategies.

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            The medical error I have chosen to talk about is surgery being done on wrong site.  Surgery is an area in healthcare in which there is prevented medical errors near misses can occur.  It had been until 1999 when the Institute of Medicine to Err is Human, is when the clinicians were unaware of the number of surgeries that were associated with injuries, death, and near misses.  There has been concern of wrong-site surgery which encompasses surgery performed on the wrong side or site of the body, which is wrong surgical procedures performed and also surgery performed on wrong patient. (NCBI,2011). 

            The wrong site surgery is defined as a sentinel event which is an unexpected occurrence involving death or serious physical injury.  It is the third highest ranking event.  It can be very devastating for the patient and negative impact on the surgical team.  The State Licensure boards are imposing penalties on surgeons.  It can be a very big deal and really bad for the patient and also their family.  It’s a really bad thing when this happens because it is bad for everyone.  (NCBI,2011). 

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            The instance of the medical error was a surgeon from Tampa it happened in 2006.  She was a hand surgeon that operated on the wrong body part of a patient.  It was the surgeon’s third mistake so I believe that it was result of an action because it was her third time of doing surgery on the wrong site.  It should not happen that much from one doctor.  The surgeon was fined $20,000 and temporary suspended from practice.  It was her third mistake in five years not much of a gap.  (Access, 2011).

            The error of the skilled base mistake I would say was knowledge based mistake because this doctor does this particular surgery and she should have had the knowledge of double checking to make sure that she was doing the surgery on the right finger because that’s what had happened all three times it was surgery on the wrong finger.  I think that when this could be common like that because it would be easy I am sure to do the surgery on the wrong finger unless they paid real close attention.

            When one would use the FMEA process to analyze the error and for recommended improvement strategies is when it was her third time of doing the surgery on three different people when she was doing surgeries on peoples fingers.  Some things that she had to do for improvement was the first time she had to pay $10,000 and was ordered to give a lecture to hospital staff on how to avoid such errors.  Then the second time she was fined $15,000 and ordered to take a course on reducing risks and do 25 hours community service and also write an article on perils of wrong procedures and also do another lecture.  Then the third time she was fined $20,000 and temporary suspended from practice.ne

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It is important to double check to make sure it is the right person and also doing surgery on the right site.  It is important to double check name and also checks to make sure they are doing surgery on the right site.  Especially when it was the third time that was a mistake.  So in the end it is important to make sure that things are being done the right way.

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References:

NCBI, 2011 – http://www.ncbi.nlm.nih.gov/books/NBK2678/.

Access, 2011 – http://www.accesscontinuingeducation.com/ACE4020/coursebook.pdf.

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