

A 65-Year-Old Woman with an Incorrect Operation on the Left Hand - mechanical_fish
http://www.nejm.org/doi/full/10.1056/NEJMcpc1007085

======
mechanical_fish
This doctor is being a good engineer. The first rule of good engineering is to
admit your mistakes as quickly as possible and as thoroughly as necessary, and
then to try to use design to avoid making the same mistake twice.

Anyway, this is good bedtime reading for those who aspire to five nines of
uptime.

Don't miss "the Swiss Cheese model of harm", and the following quote:

 _Everyone on the team should feel empowered to say, “Wait, are we sure that
what we are doing is correct?” I learned an important rule in the U.S. Air
Force: “Never worry alone.” If you think something doesn't look right, whether
you are a scrub nurse, a technician, a medical assistant, a surgeon, or an
internist, never worry alone. Stop and discuss it, because those stops result
in close calls instead of real events._

