Thomas Shaknovsky botched the surgery of William Bryan, 70, who died on the operating table
According to Shaknovksy’s deposition, after removing Bryan’s liver, the surgeon instructed a nurse to label the organ as a “spleen” – and he also identified it as a spleen in Bryan’s postoperative notes. Shaknovsky later said he had been “mentally compromised” at the time of Bryan’s death, explaining that he was “devastated, demoralized, crying over his passing, felt that I failed him”.
Though this was an idiocity, I think we need to be careful with just blaming the surgeon and that’s it.
Errors like this usually happen because of a chain of various circumstances and other little mistakes, like with airplane crashes.
I think it would be much better that we treat these sort of incidents like airplane crashes. Investigate everything that went wrong, all causes, without focussing on guilt during the investigation. Guilt can be determined from the results of that, but primarily I want that we get data on how this happened in the first place, and what we can do to avoid this from happening again. This strategy was highly successful in aviation, I’d like to see that applied here too because too much shit still goes too much wrong in healthcare
It’s been a while since I’ve operated on anyone (consentually, at least). I know some doctors can be so arrogant that you don’t ever want to second-guess them or correct them for fear of bring berated. Aren’t there other people directly over the patient who might butt in and say “hey, are you sure that’s the right part?”