Recently a hospital patient in Massachusetts had one of his kidneys surgically removed. The surgery and the loss of a kidney was a mistake and was not necessary. The patients’ records had been confused with another patients records and the result was the surgery and the unnecessary loss of a kidney.
The regulators are putting the facts together on how this happened. Clearly, there was a lot of human error involved. All of the checks and double checks did not seem to work. Sometimes you just have to accept that we are all human and that we do make mistakes. However, you have faith that the system will catch the mistakes before any damage is done. In this case, and many others, the error was missed, the system did not work and the damage was done.
This incident, and probably many others, could have been prevented by building healthcare procedures that use standardized barcode printing and scanning. Patients ID, CT scan results, lab results, medications, medical devices should all carry easy to scan data that can be used by computerized healthcare delivery systems to prevent this type of error. These modern methods are proven and now have to become part of our healthcare systems. I encourage the regulators to consider the fact that appropriate use of barcode and computer technology would have prevented this and other adverse events in healthcare.