Friday, November 12, 2010

The right way to correct an error

We all know there is the right way and a wrong way to correct an error. Back in my early years in the business world, where word processing software was just beginning, we sent out a user manual to all of 300 stores in the chain I worked for with the word 'public' embarrassingly missing the letter 'L'. It was discovered after being mailed out and we ended up making a huge joke of it and laughing at the next sales meeting. It was rather embarrassing if you think about it but nothing more. We admitted our mistake and it could not be corrected. It was done and in print and out there.

A more significant error which involves harm usually deserves immediate admission and correction. So what would you expect after a surgical error? Sometimes they can't be corrected - we took out your left kidney not your right one or we replaced your left hip not your right one. Those are clearly more than an oops. There are supposed to be procedures in place to prevent this type of error. There is supposed to be a time out where everyone agrees on what is being done.

Surgical errors are usually admitted later and made public long after. But read through this doctor's story after he realized he performed the wrong surgery by dictating his surgical notes. He decided to make it public in the Journal of Medicine and exposes the Swiss Cheese system that is followed.

This is the correct way to handle things. First he went back and corrected the error. Then he went through the system and figured out what went wrong and went public so that the system can be better corrected as more are made aware of its problems.

I think the next time I have surgery I will write notes on my body showing them what needs to be done after I am sedated. 'Please cut here along the dotted line and only remove the following items.'

No comments: