Patient falls off OR table: System error or human error?

An anesthetized patient fell to the floor headfirst from an operating room table during a laparoscopic appendectomy in Scotland. The table had been tilted into an extreme head down position to facilitate the operation. Fortunately, no injury occurred.

The Edinburgh Evening News account says that there were 10 staff members in the room at the time the case started, but no one had placed a safety restraint on the patient.

A follow -up story noted that the hospital has experienced 11 other major surgical errors in the last year including two instances of wrong-site surgery and a case in which five swabs were left inside a single patient.

An investigation by the hospital noted that the level of situational awareness of the operating room staff was inadequate, and teamwork and communication were poor. In addition, the safety culture within the operating room was described as not highly attuned to patient safety.

The staff was also distracted by mobile phone use and idle chatter.

Instead of addressing the obvious human errors such as failure to place the safety strap, which in US hospitals is clearly the duty of the circulating nurse, the hospital's plan of correction focused on the following typical system-type corrections:

• Compulsory training of 1200 staff. Although there were 10 staff for a laparoscopic appendectomy (in the US there would be 4, nurse, scrub tech, surgeon, anesthesiologist), I doubt that there are 1200 people working in the operating room of this 570-bed hospital. What will those not working in the OR have to gain from compulsory training? I wonder if anyone considered that 10 staff for an appendectomy is far too many, and that's why there was a lot of idle chatter. Six of the staff had nothing to do until the patient needed to be picked up off the floor.

• A ban on talking at key times during operations. This one will be hard to enforce. Who decides what the key times are? I also don't see what it had to do with the incident since tilting the table would not be considered a key time in the case.

• Daily meetings to improve patient safety. Good luck with that. What on earth are they going to discuss at daily meetings to improve patient safety? I predict that those meetings won't take place for more than 3 or 4 weeks.

• Sanctions for staff who fail to meet the new standards. Also be hard to enforce. How will this be judged?

I would have talked with the nursing staff and asked them whose job it was to place the safety strap. If you want to make a system change, why not clearly specify which staff member is responsible for that action? And how about using a checklist?

Five years ago, the Scottish Patient Safety Program recommended using pre-surgery meetings and checklists to protect patients. The investigation showed that in this hospital, checklists were completed about 10% of the time and often not properly. The staff claimed that they didn't have time to do the checklists. Ten people in the room for an appendectomy and no one has time to complete a checklist?

Next I would have asked the anesthesiologist where he was. Usually the job of adjusting the table is his, and the controls are at the head of the bed. He should have noticed the patient was beginning to slide off the table and intervened.

Finally I would have asked the surgeon just how much head down tilt he needed. I have never even come close to having a patient more than about 30 degrees of head down during a laparoscopic appendectomy.

Patient falling from an OR table—human error.

Wrong site surgery—human error.

Leaving foreign objects inside patients—human error.

The OR staff of every hospital counts instruments and swabs. Wrong-site surgery is 100% avoidable. This hospital had a number of appropriate systems in place. The staff simply disregarded them. Creating more meetings and rules that are unlikely to be followed or make a difference will not solve the problem of a staff with a "can't do" attitude.

Why send letters containing ricin to public figures?

You probably heard about the Texas woman who was indicted for sending letters containing the deadly poison ricin to President Obama and New York's Mayor Bloomberg.

What goes through the mind of someone who would try to send the president ricin? Did this individual really think that presidents open their own mail?

She might have thought it was something like this.

Barack Obama: "Michelle, did you get the mail today?"

Michelle Obama: "No, I didn't, honey. Would you mind doing it?

BO: "OK. I'll be right back." [Goes out the front door of the White House, goes to the end of the driveway, greets tourists through the fence, opens mailbox, grabs mail and walks back.]

MO: "Anything important in the mail?"

BO: "Not much. A bill for the healthcare of everyone in the United States, a coupon for 20% off from Bed, Bath and Beyond, some credit card offers … wait, here's something interesting. It's a letter. Hmmm, no return address, but it's postmarked 'Boston, Texas,' so it might be worth reading. I'll open it and see what it says."

Not likely. In fact, inconceivable.

Why on earth would someone in their wildest dreams think that poison sent to any prominent person would reach them?

If you think that was bad, how about the two Upstate New York men who were charged with conspiracy to support terrorism? Using an x-ray machine, they constructed a "death ray" for targeting certain groups and possibly the president.

ABC News reported the story uncritically, but the Huffington Post quoted a radiologist as saying the device was unlikely to have been effective because it would have required a large amount of electricity, would not have been very portable and any potential victim would have had to remain stationary for a long time.

One of the plotters was an industrial mechanic for General Electric, a company that makes x-ray machines.

Despite that background, he and his henchman apparently didn't consider all the details.

Neither did the ricin lady. There wasn't enough ricin in the envelopes to harm anyone.

Ricin? Death ray? What were they thinking?

"System errors" plague the NTSB and a San Francisco TV station

By now you have probably heard about the San Francisco TV station that broadcast what it thought were the names of the four pilots of Asiana Flight 214 that crashed landed last week.

The names were not those of the pilots and were typical racist stereotypes.

If you haven't seen it, here's a 30 second clip that shows all you need to know.

The station, of course, apologized and said that it had confirmed the names with the National Transportation Safety Board, which promptly blamed a "summer intern" for the debacle. This is according to an NBC News/Reuters story, one of the very few that didn't repeat the names.

That story also points out that the real names of the two pilots at the controls had been released earlier in the week.

Is another case of system errors and not human errors? Let's see.

The NTSB said, "Appropriate actions will be taken to ensure that such a serious error is not repeated." The intern was supposed to have referred such questions to official NTSB media people.

The station's vice president and general manager said, "Nothing is more important to us than having the highest level of accuracy and integrity, and we are reviewing our procedures to ensure this type of error does not happen again."

The apparently clueless anchorwoman who read the names has said, "A serious mistake was made."

Here is what spokespeople for the Asian American Journalists Association had to offer, "We are embarrassed for the anchor, who was as much a victim as KTVU's viewers and KTVU's hard-working staff."

Wait a sec. The anchor and KTVU's hard-working staff were victims?

"We never read the names out loud, phonetically sounding them out," said a different KTVU anchor.

Another AAJA member wrote, "Common sense indicates that simply sounding out the names would have raised red flags,"

Sound out the names? They were so obviously fake that a high school kid would have noticed simply by silently reading them.

How could everyone at the TV station, the producers, editors, writers and the anchor who read the story on the air with a straight face, not have noticed that the names were not only not very plausible, but also exceedingly offensive?

Also unclear is how the station acquired the supposed names in the first place.

System errors? I don't think so.

Additional source: Los Angeles Times

Search "System Errors" on my blog to see 12 other posts on this topic.

Pregnant woman dies after ovary removed instead of appendix

On June 10, 2013 a 32-year-old "heavily" pregnant woman was reported to have died after having an ovary removed instead of her inflamed appendix. As the infected appendix festered, she became septic and succumbed to multiple organ failure. This tragedy occurred in the UK in late 2011, but has just come to light.

How could this have happened?

Let me count the ways.

The surgery was performed by two trainee surgeons. Their level of experience was not stated.

The senior staff, called consultants in the UK, had gone home for the day.

The operation to remove the appendix was apparently done as an open procedure, not laparoscopic, which is acceptable if done correctly. The articles say that the surgeons had to take out the organ by feel and not under direct vision, which is not proper.

Although an ovary can be enlarged during pregnancy, under no circumstances does an ovary look or feel like an appendix. As in another case described below, inflammation can cause confusion at times, but not to this degree.

The woman was discharged a week after the initial surgery but returned with pain some 10 days after the removal of the wrong organ. During that time period, no one had checked the pathology report. The mistake was discovered by a doctor reviewing the patient's records during the readmission.

An abscess was drained but the she died on the operating table during a futile attempt to at last remove the appendix.

Last week, the CEO of the hospital sent a written apology to the family promising to correct the dreaded "system errors." Too little, too late.

Yes, there were system errors.

But what about human errors?

Trainees were allowed to undertake a supposedly routine operation without supervision. However, as this case shows, an appendectomy during pregnancy can be very difficult. The uterus is in the way, and its increasing size may displace the appendix from its normal position. This type of surgery cannot be done by "feel" alone.

Commentary from UK physicians on Twitter suggests that all the facts of the case, such as what communications took place between the trainees and their supervisor, have not been made public. They also point out that it is not mandatory for a consultant to be present in the operating room for every case as is true of the resident-attending surgeon relationship in the US.

But I doubt that many US surgeons would allow residents to operate independently on a pregnant patient with appendicitis. At the very least, the attending would have been in the OR, if not scrubbed.

Did the trainees ask the consultant for help when they found themselves doing an appendectomy by feel?

The surgeons did not look at the pathology report, a major omission. But what about the pathologist? If a pathologist receives a specimen labeled "appendix," and he finds only an ovary, wouldn't the prudent pathologist pick up the phone and call the surgeon?

There is also "failure to rescue." When the patient was readmitted, earlier recognition of sepsis and more timely intervention might have saved her life.

I am aware of a similar case in which an inflamed piece of fat was removed by two unsupervised trainees who mistook it for the inflamed appendix. On the following day, the pathologist called the attending surgeon to tell her that the appendix was not present in the specimen. The patient was promptly taken back to surgery. He wasn't too happy, but he was alive.

The hospital's investigation of this case should have taken a few days at most. If the media reports are true, disciplinary measures and remediation should have been promptly instituted. An apology should have been offered far sooner than it was.

“An extensive trust-wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again" and "… to improve systems and patient safety," said the hospital's CEO.

As I have blogged before, system changes can be instituted, but can be defeated easily by carelessness, inattention and lapses of common sense by one or more individuals.

Stories about this from the UK media here and here. Search this blog for "system error" to view other posts on system errors.

ADDENDUM April 15, 2014
For some follow-up on this sad story, click here.

The Apocalypse Is Near: Part IV

A report from Egypt says that a medical center there is treating various maladies by having patients drink camel urine. It apparently is good for “the treatment of skin diseases such as ringworm, tinea and abscesses, sores that may appear on the body and hair, dry and wet ulcers, swelling of the liver, toothache, and for washing eyes.” Ah … no, thanks.

In Britain, 26% of the population has received a diagnosis of depression at some point in their lives. That is depressing. However, it doesn’t mean that they were all clinically depressed. I don’t know what goes on over there, but here in the US, it seems all you have to do is tell a doctor you feel depressed and you will likely receive a prescription for an anti-depressant.

How’s this for chutzpah? Francesco Schettino, the former captain of the ill-fated liner Costa Concordia, has sued the company that owned the ship for wrongful termination after he was fired. You may recall that he is facing charges of manslaughter and abandoning the ship. [LINK]

Here are five stories that make me pessimistic about the future of our country.

1. A boy removed the brakes from his bicycle, promptly ran through a stop sign and crashed into a car. [LINK]

2. An adult couple who were babysitting tied a 2-year-old girl to a coffee table because she wouldn’t stay away from the refrigerator. Yes, that’s bad, but it gets worse. They “began to wonder if it was a bad idea to tie up the girl, and discussed the situation with an upstairs neighbor” who then called the police. [LINK]

3. Two law students were arrested for killing a rare exotic bird at a hotel in Las Vegas. They were tossing it around and then decapitated it. Did I mention they were law students? The article describing this heinous crime says they attended “Berkeley University in northern California.” I think the reporter meant to say University of California, Berkeley, but how would he have any way to know this since Berkeley is at least 500 miles from Las Vegas? [LINK]

4. Another northern California story details a new diversion created by boys at a high school. They started a “fantasy slut league” in which “Male students earn points for documented engagement in sexual activities with female students." This is so bizarre that even I can’t think of anything to say about it. [LINK]

5. The University of North Carolina has banned the use of the word “freshman” to denote a student in the first year of college because the term is “non-gender inclusive.” From now on, they are to be called “first year students.” The story is amusing as it points out the problems with the words sophomore, junior and senior. [LINK]