Re my prayer request for DS3 - you won't believe this!

[RoughCollie]

Stephen gets to the hospital and the surgeon and nurses tell him he is being operated on the right side. They mark his right side with a Sharpie, or whatever. Everyone is yapping and no one is paying attention to Stephen, who knows the surgery should be on his left side.

 

He is on the table, and right before the anesthesiologist puts the mask over his face, he says again, loudly, that the surgery should be on his left side. The anesthesiologist says "yeah, whatever" and puts him under.

 

They operated on his left side, and removed the original mark they put on his right side.

 

DH said that was a good thing, or Stephen would own the hospital.

 

This morning, I wrote DH an email and gave him a note in which I told him to make sure he sees the surgeon actually check Stephen's hospital record to make sure they operated on the correct side. I reminded DH of this as he was on his way out the door. DH didn't insist that he watch them check the records, like I told him to. He did say they should check to make sure they were operating on the correct side.

 

Whew! Almost had a serious situation on our hands.

 

Stephen is amazed that they were about to operate on him on the wrong side without checking the most rudimentary details. Luckily, they would have opened him up and seen immediately that they were on the wrong side, so no permanent damage would have been done, hopefully.

 

What do you say? I say prayer from you all works!

 

Thank you again, so much!

[Jean in Newcastle]

Wow. Didn't you want to own a hospital? :leaving:

[Rebecca VA]

She might not want to own *that* hospital, if they're that mistake-prone.

[Parrothead]

Wow! When dh had his surgery he was asked what side prior to marking him up. I say you were absolutely correct in your concern. Thank goodness you mentioned it.

[RoughCollie]

I didn't mention it -- Stephen did! I am just amazed at how close they came to making a mistake.

 

Stephen said the medical personnel were talking to him like he was a little child. He'll be 19 next month. I had to talk the surgeon into operating on Stephen because he was the best one around, being very experienced with this surgery, and the children's hospital in Pittsburgh doesn't take patients who are 18 or older. So they spoke to Stephen like he was a little kid probably because they are just used to talking to kids all the time, and I guess they didn't pay attention to what he had to say during all the yapping about it before he ever went into the operating room because they aren't used to listening to kids.

[RoughCollie]

Wow. Didn't you want to own a hospital? :leaving:

 

 

Since Stephen had 2 operations at the same time today, if they had made the right side incision in his abdomen, he would have had his college education paid for, no permanent harm done. But if they did the other operation first, Stephen would have owned the hospital and every asset that surgeon ever acquired.

 

Personally, I'd rather not have a bad outcome, whether it did permanent damage or was just an extra incision to heal.

 

Now I'm wondering what to do. I originally planned to write the surgeon a thank you letter, and I will, but I want to know how this near-mistake could have happened, and what they are going to do to make sure it doesn't happen again!

 

It seems like protocol must not have been followed. The surgeon must personally look at the chart to double-check that he is doing the correct operation on the correct anatomy and on the correct patient. It seems like a no brainer to me.

 

Medical negligence kills or seriously harms tens of thousands of people in the U.S. every year. All preventable.

 

http://www.cnn.com/2012/06/09/health/medical-mistakes

[justkeepswimming]

My mom had this happen when she was young and had knee surgery. They did the surgery on the wrong knee (removing cartilage or something like that). She had to heal from that and then go right back in for another surgery on the other knee. Nothing except a "whoops!" and a "free" surgery the second time. The correct knee to this day is great - but the one that was erroneously worked on has always caused her a lot of pain and irritation. :(

 

So glad your son made out on the good side of things! He must have woken up in a panic, though!! I know I would have!!

[Twigs]

Contact the hospital's department for quality and safety. They definately need to know that protocol was not followed.

I'm glad it all turned out ok.

Best wishes.

[RoughCollie]

Gosh, Hazel, I'm real sorry that happened to your mom.

 

Twigs, thanks for the advice. I'll take it! DH said the surgeon came out and talked to him twice about it and said it was a clerical error, apparently. I want to make sure this isn't swept under the rug, especially since the only reason they caught their error was their line of last defense, which they did not use properly. If Stephen hadn't said something at the last minute....

[Catherine]

Yes, agreeing that writing the surgeon might be satisfying, but for real results in the long term for other patients, write (persistently!) to the safety officer or a top administrator of the hospital. This is the kind of dumb error that the vast majority of hospitals have figured out how to prevent, but some are still learning a hard lesson about it, apparently.

 

If anyone is interested, Atul Gawande wrote a really thought-provoking book about medical errors, operating room errors and their prevention, really, The Checklist Manifesto: http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000/ref=sr_1_1?s=books&ie=UTF8&qid=1360672305&sr=1-1&keywords=checklist+manifesto

 

The book explores how some industries have coped with error prevention and safety, and how that might be profitably applied to surgery and other areas of endeavor.

 

RoughCollie, I would seriously look at another hospital for your son's future needs. Really, that kind of mistake is unbelievable.

[Acorn]

For my surgery the actual mark was a no on the wrong side. The surgery side was disinfected and prepped. I hope your son heals well.

[Lizzie in Ma]

I believe it, thanking God they did it right. Hoping for quick healing and no more stress for you all.

[somo_chickenlady]

I agree with Acorn...when DH had surgery on his knee, they marked the wrong one so they would know it was the wrong one and wouldn't accidentally do sugery on it. Quite a few hospitals do that, actually. I know the Children's Hospital that I worked at did as well.

[DragonFaerie]

Okay, I just have to say that when I saw the thread title, I thought your son was 3 years old. I read your whole post thinking, "Wow! What a smart three-year-old!" :D

 

(Yes, I saw, belatedly, that you have the ages of your kids in your siggy. I'm just not that bright. hehe)

[Excelsior! Academy]

Okay, I just have to say that when I saw the thread title, I thought your son was 3 years old. I read your whole post thinking, "Wow! What a smart three-year-old!" :D

 

(Yes, I saw, belatedly, that you have the ages of your kids in your siggy. I'm just not that bright. hehe)

 

Me, too!

 

 

So thankful they caught it in time!

[Supertechmom]

New standards dictate what is called "time out" when the pt goes under and before anything else is done, the OR nurse calls time out and reads the pt name, condition, what they are doing and whatever else pertinent info is needed. The surgery and what site is given. Each of the team member is supposed to verbally agree with the check off. Hopefully, that was done and that is why it was caught. BUt it is called time out and you can suggest that in your letter that they follow the time out rules and double check the consent and pre-op check off routine.

 

Glad it was caught.

[mrseshaw]

Contact patient relations at the hospital and tell them your story. my experience with them at a large boston hospital was very fruitful.

glad your little guy spoke up, and is hopefully recoving well.

[ZeeMommy]

Register a complaint with the hospital, and here http://www.jointcommission.org/report_a_complaint.aspx. Joint Commission has standards hospitals adhere to, and they rate/review hospitals and other medical facilities. Complain to make sure that this doesn't happen to someone else's loved one - an error is an error, especially in medicine, clerical or not.

[somo_chickenlady]

It may not have been an error or something they caught...quite a lot of hospitals mark the wrong side on purpose. Just saying.

[RoughCollie]

It wasn't a case of marking the side not to be operated on. The surgeon told DH they were going to operate on Stephen's right side, and then discovered a clerical error had been made. The doctors and nurses had repeated stated to DH tht they were going to operate on Stephen's right side, before Stephen entered the operating room. They did not ask Stephen whether that was correct, and they did not give him a chance to speak up for himself. This treatment of Stephen is typical around here -- very authoritarian, children to be seen and not heard unless asked a question directly. (Stephen asked me last night when "children" are considered be equal adults, for this reason.)

 

I wonder if they didn't consult Stephen because he has Asperger's. There are an awful lot of people who don't understand the syndrome, and who judge people who have it in a biased manner. Stephen was worried about that too .... how is he going to cope with people who think Asperger's causes someone to commit a mass killing of children, and so forth? How about those who think people with Asperger's are stupid or unworthy in other ways?

 

Apparently, they have a cheat sheet that summarizes what the surgeon needs to know, and it said that the right side was the one to be operated on. This is what horrifies me -- this cheat sheet is no substitute for the patient's actual medical record and using one is just another way an error can occur.

 

When Stephen said, very loudly, that his left side was to be operated on, and then was put under immediately, someone in the operating room must have insisted that the medical record be checked.

 

IMO, the protocol needs to be changed and/or enforce if this is against protocol. Also, I'd fire the person who made the clerical error. S/he should have at least carefully double-checked that important information was transferred to the cheat sheet correctly. No second chances! This is a matter of not being meticulous when a mistake could lead to death or grievous bodily harm.

[PollyOR]

:scared: Wow! The fact that the anesthesiologist blew him off is what bothers me.

 

When DH had knee surgery the second time, they put a sticker of a stop sign on the other knee.

 

I had surgery Friday. I lost count of how many times they verbally verified with me which side the doc was going to operate on. He signed my side with a marker and later a nurse checked the mark right before they wheeled me off into surgery.

[zimom]

My daughter has had surgery three times on her right leg. Without going into too much personal detail of her birth defect, it is OBVIOUS her right leg is the one that needs the surgery, but each time, two different hospitals, the nurse writes NO on her left leg and they have me initial her right leg. The leg to be operated on is reviewed by no less then three different people, not just stated, but they wait for me to confirm.

 

My husband had leg surgery after shattering his leg this fall, a third hospital, and they did the same thing. After confirming with him, they wrote NO on the good leg, had him initial his cast, silly as it seemed, and several staff confirmed the correct leg along the way.

 

To me a big point is we are talked to at all steps, or if we don't feel adequate communication, everything stops until we are heard as ultimately we need to take as much responsibility for our healthcare as we possibly can.

[Twigs]

… IMO, the protocol needs to be changed and/or enforce if this is against protocol. Also, I'd fire the person who made the clerical error. S/he should have at least carefully double-checked that important information was transferred to the cheat sheet correctly. No second chances! This is a matter of not being meticulous when a mistake could lead to death or grievous bodily harm.

 

I'm sorry, but I disagree with firing the person. It shouldn't be just 1 person's responsibility. If it was just 1 person's fault, and s/he got careless, a big scare like this could turn him/her into the most conscientious employee ever who might then warn all co-workers about what happens when the protocols are not followed. Even in life & death situations, mistakes will happen. Our best hope is to reduce the frequency of mistakes and that can only be done by conscientious people who care. If the person was a true goof-off, then firing may be right thing to do.

 

Also, you don't really know all the circumstances about what was going on. In today's world, there is an incredible push (usually by upper management who never even sets foot in the actual work area with actual work going on) to do things faster (for economy's sake). I worked in the medical field long enough to know that hurrying to get more work done inevitably leads to errors.

 

I hope your son is getting better!

[jelbe5]

Wow. I just had outpatient surgery on my right knee. One of the first things they did when I checked in at the hospital was put support hose on my left knee, effectively covering it up. Various staff asked me (and documented) which knee I was having done. Right before I went for surgery the doctor came and asked me one more time which knee was I having surgery on and then marked the surgery knee with a sharpie. I thought it was a little bit amusing, but I was glad they were so careful.

[Forget-Me-Not]

I'd bring down the wrath of the Joint Comission so fast their heads would spin.