A must-read RT @Atul_Gawande: Lessons: how a surgical team operated on the wrong leg, and what they did after. http://bit.ly/1d7Ti3e
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Impressive! “
@Atul_Gawande: Lessons: how a surgical team operated on the wrong leg, and what they did after. http://bit.ly/1d7Ti3e ”Thanks. Twitter will use this to make your timeline better. UndoUndo
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@Gmanattack you must be the first person ever to ask that question that way round!@Atul_GawandeThanks. Twitter will use this to make your timeline better. UndoUndo
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@Atul_Gawande@traumagasdoc Unfortunately we had simialr episode.@NHSEngland hasn't learned/disseminated the lessons http://oriordan.co.uk/blog/files/Failing%20to%20learn.html … -
@dermotor@Atul_Gawande@traumagasdoc@NHSEngland What about dissemination via CORESS? http://www.coress.org.uk/ -
@NatalieBlencowe@Atul_Gawande@traumagasdoc@NHSEngland I did specifically ask for it to go to CORESS. Need to check this actually happened
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@tom_peters Interesting/scary story about QA in surgery MT@Atul_Gawande: how a surgical team operated on wrong leg. http://bit.ly/1d7Ti3e -
@garynissen@atul_gawande I think the US average is several of those per week. Guarantee you not isolated incident. -
@tom_peters@Atul_Gawande But public share not so common. Impressed how strongly the event touched those involved, how simple root cause. -
@garynissen@atul_gawande Enormous share of patient safety problems are caused by hyper-fixable lapses. That's the maddening part. -
@tom_peters@garynissen@Atul_Gawande People react to HC error as if it's rare, punishable offense. Systemic problems - chronic not acute - 1 more reply
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@CatLadyMD “@Atul_Gawande: Lessons: how a surgical team operated on the wrong leg, and what they did after. http://bit.ly/1d7Ti3e ”Thanks. Twitter will use this to make your timeline better. UndoUndo
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@Atul_Gawande How many other learning opportunities are covered up? Why don't we treat surgical errors like plane crashes ? Be#antifragileThanks. Twitter will use this to make your timeline better. UndoUndo
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@Atul_Gawande WHO checklists can fail if done by busy OT staff. Multiple entry checks at preop area, verbal cross check with pt must be doneThanks. Twitter will use this to make your timeline better. UndoUndo
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We can all learn from this:
@Atul_Gawande: how a surgical team operated on the wrong leg, and what they did after. http://bit.ly/1d7Ti3e ”Thanks. Twitter will use this to make your timeline better. UndoUndo
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@Atul_Gawande thanks for sharing the story! Much appreciated! HelgiThanks. Twitter will use this to make your timeline better. UndoUndo
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“
@Atul_Gawande: Lessons: how a surgical team operated on the wrong leg, and what they did after. http://bit.ly/1d7Ti3e ” Time-out essential!Thanks. Twitter will use this to make your timeline better. UndoUndo
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