From the archives of The New York Times is a case of a surgeon who amputated the wrong leg for a patient in a Tampa care facility. The case happened on February 20, 1995, when Dr. Rolando R. Sanchez mistakenly operated on the wrong leg for Willie King, aged 52 (“Doctor who cut off wrong leg is defended by colleagues”, 1995). Dr. Sanchez was arraigned in court following the event, and his license was revoked alongside his poor reputation in the medical practice. Together with his lawyer, Mr. Michael Blazieck, the physician sought to regain his license through a series of legal hearings that were presented by State officials who would determine his professional future for Dr. Sanchez. According to the surgeon and the lawyer, the incident was not intentional, and it occurred due to a raft of errors in the healthcare facility at University Community Hospital in the region.
The blackboard that contained the list for operations at the theatre had listed the wrong leg. Additionally, by the time the doctor was getting into the computer system, King’s wrong leg had been sterilized, ready for the operation, testimony showed. Doctors who had witnessed the incident said that the two legs were in poor shape and the patient would be amputated in the future (“Doctor who cut off wrong leg is defended by colleagues”, 1995). However, Steven Rothenburg, a legal practitioner who pressed the case against Dr. Sanchez, said that the surgeon should have checked all the details prior to the operation.
The matter at hand, in this case, was the allegations that the surgeon posed a critical danger to the health and safety of patients in terms of the welfare that covers up to the public perspective. Dr. Sanchez said that the mistake did not lead to his dismissal from medical practice and that he deserved a chance to continue with his work. The patient did not have a way to go about the matter but generally termed an existence of a problem that needed to be corrected. He had been compensated by the surgeon and the University Community Hospital.
How various Factors Might Have Contributed to the Wrong-limb Surgery
There are various factors that may lead to latent errors in care facilities. The first is institutional or regulatory, which may lead to pressure on improving the delivery of services. The second factor is management, whereby Dr. Sanchez might have been informed to confirm all the details by the nurses but disregarded by assuming that the preparations done were enough to have background data concerning the operation (“Root Cause Analysis”, 2019). Additionally, the work environment might have probed the surgeon to do the operation without confirming due to the failure of electronic health records.
Team environment matters as well, assuming that the surgeon might have needed additional staff to complete the task but went ahead to do it himself without involving his colleagues. There is also an issue with staffing in that Dr. Sanchez may have been overworked and felt tired when he started the operation (“Root Cause Analysis”, 2019). The task-related factor means that the two legs appeared to have needed surgery in which the doctor may not have doubted any mistake. Patient characteristics are a key determinant because King might have failed to follow up on the activities underway due to incompetence or ignorance when it came to confirming the background details before the operation started.
Qualitative Assessment of how Much Each Factor Contributed to the Error
Institutional factor means that University Community Hospital was under watch on the depth of medical services they had in the society depending on their rating. If the hospital was highly ranked, then the staff might work under significant pressure to meet the demand of completing surgeries as per the institutional expectations from the stakeholders (“Root Cause Analysis”, 2019). Management, in this case, may be due to poor coordination where information from nurses may not count when a doctor is present, which might be facilitated by a lack of confidence in all staff. Lack of network to update the records means that Dr. Sachez might have failed to systematically go through the computer systems hence, missing the evident inconsistency in the matter.
Teamwork matters in every field of work, and all people must equally show interest in working together. If the nurses and other doctors did not show togetherness, Dr. Sanchez might not have realized the possibility of the wrong surgery. If the facility has an insufficient number of workers, it means the latent error may occur due to sole decision-making without consulting others who may be busy with other tasks. The fact that the two legs appeared to be complicated means that Dr. Sanchez did not guess any inappropriateness while conducting the surgery. Patient characteristics include ignorance and lack of exposure to medical experience. King could be facing an issue with his intellectual capacity hence not being able to spot possible occurrence of an error.
Recommendations
The recommendations, in this case, include a review of background data before starting a medical procedure that might have a permanent impact. For example, the surgeon needed to conduct an analysis by use of computer systems or ask other healthcare workers about the operations before starting. The other recommendation is the incorporation of teamwork. For instance, the doctor should have started the operation in the presence of a nurse or another doctor. If the two recommendations are put into practice, there would be no or few cases of latent errors.
References
Doctor Who cut off wrong leg is defended by colleagues. Nytimes.com. (1995). Web.
Root cause analysis.PSNet. (2019).