A 65-Year-Old Woman with an Incorrect Operation on the Left Hand

http://www.nejm.org/doi/full/10.1056/NEJMcpc1007085

1 1 16 years ago

This doctor is being a good engineer. The first rule of good engineering is to admit your mistakes as quickly as possible and as thoroughly as necessary, and then to try to use design to avoid making the same mistake twice.

Anyway, this is good bedtime reading for those who aspire to five nines of uptime.

Don't miss "the Swiss Cheese model of harm", and the following quote:

Everyone on the team should feel empowered to say, “Wait, are we sure that what we are doing is correct?” I learned an important rule in the U.S. Air Force: “Never worry alone.” If you think something doesn't look right, whether you are a scrub nurse, a technician, a medical assistant, a surgeon, or an internist, never worry alone. Stop and discuss it, because those stops result in close calls instead of real events.

A 65-Year-Old Woman with an Incorrect Operation on the Left Hand

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