Today I Learn… I make a point of learning something new everyday. This is what I learn each day

1, Jul 13, 2010

Shattering the Myth of Trust, Taking Care of Ourselves (6)

Filed under: Medical Accident — admin @ 12:05 am

As I have been kept being shocked by what I read about medical accidents from this book, I feel compelled to share these with my readers so that patients will know they need to take extra care of themselves when they are with their doctors. After all, to err is human and we don’t want this kind of error made on us.

This chapter focuses on wrong limb. pp. 121-125. It happened on Feb 20, 1995 when Dr. Rolando R. Sanchez, a Tampa, Florida surgeon, amputated the wrong leg of a 52-year-old patient name Willie King.

King had suffered for years from diabetes. As the result, the nerves in his legs were beginning to deteriorate, so severe was his problem that on 2/17/1995 he agreed to amputate his right leg below the knee, a below the knee amputation (BKA), a common procedure for advanced diabetics.

The computer schedule printout had it “patient Willie King — a left BKA.” The heads-up floor nurse spotted the mistake and called the operating room. The nurse receiving the call made a hand-correction on the printout without correcting the error in the system. Hence further printout showed no correction at all.

The surgeon saw the original printout, was mentally prepared to cut off one leg, without further checking which leg that needed to go. Here he went and the patient’s left leg was gone.

We have to remember this wrong-limb chopoff horror so that we will do the check and remember to remind the doctor which one need work before anesthesia knocks us down.

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