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Wrong site, wrong side and wrong patient procedure

Suri Prabhu yes - i know July 8 at 8:48pm Like

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Chandrashekhar Tengli unbelievable stat!!!

Rajesh Kalra BY some estimates, wrong site, wrong side and wrong patient procedures occur more than 40 times every week in the United States. What about us?

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July 8 at 8:39pm Like Harsh Tripathi but I like ur honesty and I am sure u have learned ur lesson

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July 8 at 8:16pm Like Unsubscribe Suri Prabhu has happened to meJuly 8 at 8:43pm Unlike person 1

July 8 at 8:48pm Like

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Suri Prabhu yes- i have learned and i hope those mistakes are never reapeated-

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Harsh Tripathi God only knows?????

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July 8 at 8:22pm Like Harsh Tripathi just once or many times July 8 at 8:47pm Like

July 8 at 8:49pm Like

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Harsh Tripathi Amen!

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Pankaj Aggarwal Never happens with me....i always check myself each and every case positively.....i dont know about the other surgeons in india......might need a retrospective study... July 8 at 8:35pm Like

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Suri Prabhu more than once-

July 8 at 8:51pm Like

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July 8 at 8:47pm Like

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Rajesh Kalra Its a reality. July 8 at 8:54pm Like

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Harsh Tripathi one has to be extra careless and ignorant to operate on wrong site, wrong side and wrong patient. July 8 at 8:38pm Like Harsh Tripathi gotta be careful dear

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July 8 at 8:48pm Like Harsh Tripathi I dont doubt ur credentials Rajesh Sir July 8 at 8:59pm Like

Suri Prabhu yes - but many a slip twixt the cup and the lip

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Suri Prabhu yes - and these things do not happen when one is a tyro - they happen to veterans who delegate responsibilities and then (foolishly) expect that they run a tight ship (when all the supporting staff are passing the buck of responsibility when they prepare the checklist) July 8 at 8:59pm Like 1 person

July 8 at 10:14pm Like

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Prahlada Nayaka Basavanthappa It happened to me once. I almost operated on a wrong ear. My assistant had scrubbed and draped the patient and had given LA injections also. Patient was for Tplasty and when examined under microsocpe as a practice before starting, to my utter shock I found a normal TM? When verified the record I realized the mistake. Now I dont trust any one as far as identity of the patient, site of surgery and side of surgery. Not even my memory and not even my wife!!! July 8 at 11:33pm Like person 1

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Sarvejeet Singh winning is not which teaches us but it`s loosing which teaches us. ! like we never appreciate water till we are thirsty like we never appreciate air till we cant breath it`s not what we have makes us go on but it`s what we dont have makes us go on.! so we gotta loose to win some day ! July 8 at 10:43pm Like person 1

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Harsh Tripathi bang on Dr suri July 8 at 9:00pm Like

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Suri Prabhu and the golden quality of a good (assistant) nurse is the ability to say -"NOT ME" when questioned about a lapse in protocol! July 8 at 9:01pm Like Prahlada Nayaka Basavanthappa Actually less. In India the barrier between a doctor and a patient is very less, therefore, not many mistakes happen. Where as in US, the barrier is too much. There are counsellors, insurance guys, orderlies, nurses, theater nurses, coordinators, social workers ... so on. July 8 at 11:24pm Like people 2 Suri Prabhu because the only ones who keep control over us are our wives - who say "nah re- be good - god is watching" July 8 at 11:34pm Like

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Prahlada Nayaka Basavanthappa Harpreet Singh Kochar: Talking of operating without indications and sham surgeries, I thought this happens only with Tonsillectomy. When started discussion on CI Monopoly, to my utter shock, many people posted that even CIs are being done when not indicated! July 8 at 11:37pm Like

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Sumit Mrig A routine protocol to Mark the site of surgery preop would prevent such a blunder... July 8 at 9:41pm Like

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Harpreet Singh Kochar but India would take away the trophy in operating without indications and sham surgeries. July 8 at 11:31pm Like person 1

July 9 at 8:59am Like

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DrKumaresh Krishnamoorthy During my fellowship twice I found that the wrong side was indicated. It is because there the nurses are the ones who make bookings. The side and the films did not correlate both the times and when through the record found that it was the wrong side, both the pts were AN. JCI protocols help in reducing this. July 9 at 6:12am Like

DrKumaresh Krishnamoorthy This book was give free to all consultants as part of JCI training July 9 at 12:13pm Like person 1

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Rajive Bhatia During my residency, I discovered that wrong side had been shaved so summoned the barber & got the correct side also shaved up. the barber was a little upset & did it very ganarously. the poor patient sported a punk haircut for the postop period. July 9 at 9:00am Like 1 person

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Rajesh Kalra https://docs.google.com/vi ewer?a=v&pid=explorer&chro me=true&srcid=0B-VMH12vwJ_ DOGIyYTRhN2YtYzY3OS00NTc4L TlmYzQtMmEwZTZhZWY2NGNl&hl =en_US The link for Dr. Atul Gawande checklist July 9 at 12:33pm Like person 1

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Rajesh Kalra Use site markers EUM must before starting Ear Surgery. Read CT again & correctly at table. Faith in others may cause error. Avoid multi tasking. Analyse near misses Use a ckeck List July 9 at 6:27am Like 4 people Arvind Soni In our hospital due to JCI protocols this is nonexistant. marking of the site and then "Time Out" in the O.T. (with patient on the table) by anaesthetist, sister and surgeon leaves nothing to chance. July 9 at 10:04am Like people 2

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Suri Prabhu hehe ! - good and true - but this really happened - at a busy hospital, with a busy ENT and a busy Pediatric surgeon - a child posted for circumcision came out (of the theater complex) with tonsils removed! July 9 at 3:19pm Like 2 people

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DrRajeev Adhana always recheck before surgery.... July 9 at 8:31am Unlike person 1 Prahlada Nayaka Basavanthappa One should read "Checklist Manifesto" by Dr. Atul Gawande of USA. He is the one who created this WHO Protocol which JCI has adopted later. A great tool but not many people are following it. July 9 at 10:14am Like person DrRajeev Adhana achche husband aur achche surgeon ko thoda shakki hona chahiye....this was master sentence by our teacher DR JP PUROHIT,JHANSI. 1

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Suri Prabhu ^^ hehe - the site for circumcision might have been marked with an arrow pointing but probably covered with a small lungi/loin cloth - thus confusing the OR staff!! July 9 at 8:02pm Like 1 person

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fixed to only surgeon and circulating nuse after enquiry. Your comments.........

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Rajesh Kalra Worst affected specialty is Orthopaedics (87 % cases in one study in UK). July 9 at 8:34pm Like 1 person

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July 11 at 9:56am Like Jagdish Dhingra US perspective. I disagree with the comments that there are a number of people between the surgeon and the patient. I am not aware that there is any good comparative data between countries, but having worked in India, UK and USA; I am convinced that mistakes happen everywhere. USA is not unique. Kudos to Atul for his work. Agree that Checklist Manifesto is a good read. July 11 at 2:46am Unlike person 1

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DrKumaresh Krishnamoorthy The onus is on the surgeon and he is liable for penalty July 11 at 10:20am Like

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Ravi Meher thanks sir Rajesh Kalra for uploading the Dr. Atul Gawande check list , its really useful and i will try to implement this in our institution. July 9 at 9:42pm Like

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Surinder K Singhal Dr Krishnamoorthy, it was in the past that the surgeon was thyought to be captain of the ship. Those days there no qualifies paramedical staff and technicians and nurses.Now everybody starting from paramedical staff, staff nurse and anaesthetists are qualified and they have their defined duties.They are responsible for their own deeds. If a staff nurse fails to identify the patient and shift him / her to wrong table, she is responsible. If an anesthetist administers general anaesthesia to aptient whom LA was to be given, he is responsible. He can change the type of anesthesia but with consultaion to the surgeon. Rather in this case the surgeon detected the fault and you are saying surgeon is responsible. July 15 at 8:59am Like

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Rajesh Kalra thanks to Prahlada Nayaka Basavanthappa for this July 9 at 9:49pm Like

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Prahlada Nayaka Basavanthappa Dear All: This Check list has not only reduced number of complications, it is also saving me lot of time. Time is something which many surgeons not giving much importnace. For me time is money. By working systematically I have reduced my surgical time 50% less than standard average. July 9 at 11:15pm Like person 1

Surinder K Singhal This has happened in our institute once .This can happen to any body esp at places where so many health personals are working. To add to it when you have two pts with same name and same sex.Like in govt. set up. The SR in OPD mades the list mentioning same CR no. for two patients of same name and sex. One was admitted pt for sup. parotidectomy and second was outdoor patient for DCR. When the aprotid patient was called the DCR patient came and the satff nurse without realizing and checking the name of operation shifted the pt to OT table. SR anesthesia also didnot check the name of the opeartion and induced GA. During this time the surgeon busy writing the notes of prevoius patient. As there was no SR in the OT on that table so the surgeon asked the staff nuese to scrub and drape the pt. When the surgeon came he incised and founsd the underlying tissues normal , stopped and asked for the details of the pt. The incision was closed and DCR was done as the patient was for DCR wrongly shifted and aneasthetized by anaesthtetist. The penality was

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DrKumaresh Krishnamoorthy Surinder K Singhal Well we can talk about appreciating and talk about legality. In the court of law the surgeon is responsible. I know of instances where the mistake was not the surgeons but he has been sued. Also I know of a judgement wherein the courts have clearly said the onus is on the surgeon. Yes I too would like my paramedical to be perfect, in fact we believe them and our juniors hoping and thinking they are right, but sometimes it does not happen so. I still stick to my stand that the surgeon is responsible for his/her patients. July 15 at 11:05am Like person 1

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