To err is human
November 17, 2008 § 6 Comments
This week one of the worst cases of retained surgical instruments in Norway was unraveled. A patient saw his five operations for colon cancer in a year turn to six, when it was discovered the surgeon had left behind a 20 cm long flexible sponge. The unique aspect of it however, was the patient’s reaction.
The patient had had a colostoma for a year and was looking forward to getting his colon tucked back in and reconnected. About a week after the operation he had a fever, and on returning to the hospital an x-ray revealed the retained sponge. But that’s not the whole story. Not only had the sponge count gone wrong, but it was discovered that a radiologist had noted the foreign body on a postop x-ray report, but no one had acted on it.
In other words, the patient had all the reasons in the world to go ballistic and see his surgeon in court. But he didn’t. In fact, he asked for the same surgeon to remove the sponge. His comment to the newspapers was (my translation):
Do I have confidence in the hospital after this? Yes, I do. To err is human. (…) The surgeon did a terrific job of stitching together my colon, and I wanted him to finish it.
I don’t know how I would react in his place, but I certainly admire his attitude. The hospital routines should have prevented this ever happening, and it would be fair to give the patient some sort of compensation for his troubles. But surgeons are not omnipotent deities, although they do have our lives in their hands. We should demand that they do their very best, but we cannot demand that they never do any mistakes.
It’s not that I don’t understand patients who do get angry when these things happen, but what makes the better surgeon: being allowed to learn from your mistakes and correct them, or to work under the constant threat of having your ass sued? Just asking.
PS. If anyone knows the technical name for this sponge, please tell me. I know I’ve heard it, but I simply cannot remember.