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It was Alexander Pope, poet of the Enlightenment, who lent this famous line from his 1711 treaties, ”An essay on criticism to the USA institutes of Medicine’s report on patient safety”— To err is human.
The fact is, in the context of medicine practised today under the public microscope, this cliché very much holds true, such that every error made may easily find its way into the media, and rightly so. In fact, this propensity to professionally err has for centuries burdened the surgical profession vis-a-vis, surgical instrumentations being forgotten in patients. However, it only took two brain cells to arrive at a solution to this catastrophic error. Namely, the nurse responsible for surgical instrumentation would count the individual instruments before the surgery. Which means he/she counts the number of artery forceps, lancets, gauze etc. The surgeon then follows in doing the same and also the assistant surgeon. Then with numerical concordance between the parties, the anaesthetist would make a documentation of the individual numbers.
Thereafter, with the surgery completed, the counting exercise is repeated to ensure that the numbers before surgery concur with the numbers after surgery. However, If for example, after surgery there is less gauze than before surgery, that would suggest that the gauze is in the patient. Thus, a simple search is undertaken within the patient opened cavity, before the patient is surgically sutured closed.
For this is a very simple process that entails toddler level counting, therefore it comes as a surprise that once again, a packet of gauze was left in a patient, under this PPP Healthcare. In fact, this perennial problem, dating back to my days in medical school, speaks to doctors failing at the most basic of hurdle. But the irony is, while this doctor failed to count the gauze, Dr. Frank Anthony was in deep slumber, sleep talking on solid organ, cornea, an stem cell transplant. For this dichotomy speaks to the point consistently made— Aim to get the basics right before venturing into the complex. For this the reality, the complex will present increase likelihood of complex errors, if not mastered in the basics.
Dr. Mark Devonish MBBS MSc MRCP(UK) FRCP(Edin) FRCP
Consultant Acute Medicine
Nottingham University Hospital