

Anatomy of Error: A surgeon remembers his mistakes - danso
http://www.newyorker.com/magazine/2015/05/18/anatomy-of-error

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chernevik
Awareness of fallibility is an important driver of reliability.

I met my surgeon on a gurney just before a shoulder operation, and joked with
him that we had considered writing "not this one" on the good shoulder. He
smiled, and then handed my then-wife a pen, saying "Write that. Things like
that happen all the time." And I felt that much more confident in him, because
I think people who know they can do something stupid are so much less likely
to actually do them.

~~~
glomph
I don't know how widespread this is, but when I went to get surgery on my foot
(NHS in the UK) they literally drew an arrow on my leg with a marker pen to
avoid operating on the wrong foot haha.

~~~
jeffasinger
I recently had shoulder surgery.

One of the first steps the day of was the surgeon coming in, talking to me,
and initialing the shoulder he was to operate on.

Every new person I met along the way asked me what shoulder it was, and then
wanted to see the initials before continuing.

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s_dev
I don't think entrepreneurs or developers can look back on their mistakes with
the same regret as surgeons or medical people. Watching a startup fail or a
complete failure of a payment system is probably nothing compared to the
opportunity cost involved when its someones life.

I barely have the emotional maturity to handle a breakup -- never mind a
mistake that cost someone their life or even a finger. Certain structural
engineers or medical device engineers might face such decisions but the vast
majority of devs and tech people don't.

~~~
joshvm
Developers are less likely to be directly responsible for the sort of things
that surgeons are, unless you write mission-critical software. However, if you
write any kind of software that a lot (millions) of people depend on, there is
a very good chance that you've ruined people's lives or even caused death.

I dread to think how many people's relationships have been destroyed because
the developers of Facebook, Whatsapp, Telegram et al decided to implement read
notifications/"last seen" on their instant messaging apps.

~~~
DanBC
There are some cases in England of post office managers going to jail because
the Post Office software audit trail made it look like those managers were
defrauding the post office. It turns out there might be severe bugs causing
these errors

[http://www.bbc.co.uk/news/uk-23233573](http://www.bbc.co.uk/news/uk-23233573)

Suicide is complex and I don't want to ascribe a simplistic reason to suicide,
but at least one post office manager died by suicide after a wrongful
accusation.

A bungled software update left many people in the UK without access to their
money for weeks. At least one person was imprisoned for that - they had to pay
a fine by a certain date; they tried to pay but couldn't; even though this was
totally outside their control the system wasn't flexible enough to cope.

[http://www.bbc.co.uk/news/technology-21280943](http://www.bbc.co.uk/news/technology-21280943)

British Gas allows some people to make weekly payments as part of a payment
plan scheme. But you have to pay exactly that amount on exactly the agreed day
or their software does not recognise the payment as part of the plan. EG you
agree to pay £10 every Friday. On Wednesday you start by paying £20, then on
Wednesday you pay £12, and you continue to pay £9 or £12 every Wednesday.
You're always actually paid more than your plan agreement; and your actual
balance is in credit; but you'll be getting aggressive "red" letters from
British Gas telling you that you have not kept up to date with your plan and
that your account is in arrears. British Gas, and I say this as politely as I
can, are fucking scum.

~~~
arethuza
"At least one person was imprisoned for that" \- I initially thought you meant
someone at RBS was imprisoned, which would have been interesting...

~~~
pascalmemories
Sadly, the RBS debacle led only to knighthoods, bail-outs and taxpayer money
being spent on bonuses so they could "retain world-class talent". Apparently,
firing their asses would have been a Bad Thing due to their stellar
performance to date (and since).

The very idea of prison time for RBS re-cycling the Enron ideas of debt
vehicles is laughable.

Enron people went to jail and the banks (like RBS) then had regulators permit
exactly the same debt-swap bullshit that killed Enron. Banks went on to trade
in debt - an eventual cause of the financial meltdown. RBS was a major
culpable party but their chairman, Fred Goodwin, managed to get away with
returning the knighthood and a fraction of his pension, while protected by a
super-injunction making it illegal to reveal to the public he was a banker[1].
He continues to enjoy 'Royal Family' level police protection, has his
properties removed from Street View [2] and is granted a level of
establishment protection no-one else could dream of if they had been
responsible for any catastrophe of even a fractional proportion.

[1] [http://www.theguardian.com/business/2011/mar/10/fred-
goodwin...](http://www.theguardian.com/business/2011/mar/10/fred-goodwin-
superinjunction-banking) [2]
[http://www.theguardian.com/technology/2014/jun/20/fred-
goodw...](http://www.theguardian.com/technology/2014/jun/20/fred-goodwin-
house-removed-from-google-street-view)

~~~
arethuza
Not long after he left RBS I was crossing a zebra crossing on George Street
Edinburgh and I noticed a chap in a convertible Ferrari waiting for me to
cross and I thought the driver looked rather familiar.

Took me a few moments to realise it was our very own "Fred the Shred" out for
a quick spin....

[95% certain it was him]

------
mhuffman
I suspect a lot of this would be more difficult now. I had minor surgery not
long ago and (while I was still conscious) everyone in the room (including me)
had to agree what was about to happen, sound off about their part in it, and
confirm that they had everything they needed for their part, before
continuing.

It did make me feel more comfortable about he process.

~~~
ubernostrum
There's a fair bit of evidence that -- regardless of how they might seem at
first -- these types of "checklist" procedures really do reduce error rates.
Much of it is cross-pollination from aviation safety, where use of checklists
has been standard procedure for a long time.

This New Yorker article talks a bit about the early days of aviation
checklists, and some attempts to apply them in medicine, including a hospital
which tried checklists as a method of avoiding common causes of line
infections with IVs. The result:

 _These steps are no-brainers; they have been known and taught for years. So
it seemed silly to make a checklist just for them. Still, Pronovost asked the
nurses in his I.C.U. to observe the doctors for a month as they put lines into
patients, and record how often they completed each step. In more than a third
of patients, they skipped at least one._

 _The next month, he and his team persuaded the hospital administration to
authorize nurses to stop doctors if they saw them skipping a step on the
checklist; nurses were also to ask them each day whether any lines ought to be
removed, so as not to leave them in longer than necessary. This was
revolutionary. Nurses have always had their ways of nudging a doctor into
doing the right thing, ranging from the gentle reminder (“Um, did you forget
to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse
bodycheck me when she thought I hadn’t put enough drapes on a patient). But
many nurses aren’t sure whether this is their place, or whether a given step
is worth a confrontation. (Does it really matter whether a patient’s legs are
draped for a line going into the chest?) The new rule made it clear: if
doctors didn’t follow every step on the checklist, the nurses would have
backup from the administration to intervene._

 _Pronovost and his colleagues monitored what happened for a year afterward.
The results were so dramatic that they weren’t sure whether to believe them:
the ten-day line-infection rate went from eleven per cent to zero. So they
followed patients for fifteen more months. Only two line infections occurred
during the entire period. They calculated that, in this one hospital, the
checklist had prevented forty-three infections and eight deaths, and saved two
million dollars in costs._

[http://www.newyorker.com/magazine/2007/12/10/the-
checklist?p...](http://www.newyorker.com/magazine/2007/12/10/the-
checklist?printable=true)

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thanatropism
Economist/policy pundit here: christ, our profession needs to start doing
this.

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pcunite
A dentist once pulled the wrong tooth. I could not really afford a crown, so I
was going to have it taken out (long time ago). Thankfully it was a wisdom
tooth (I have room for them).

The look on his face after the procedure was one of shock. He gave me a free
root canal and crown for the original bad tooth.

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parados
Here is another attempt to try and get health care systems to learn how to
deal with fallibility. In this case a woman died unnecessarily during a minor
operation, however her husband was an airline pilot and he is now trying to
teach the UK National Health Service the lessons that airlines learned long
ago: [http://www.newstatesman.com/2014/05/how-mistakes-can-save-
li...](http://www.newstatesman.com/2014/05/how-mistakes-can-save-lives)

~~~
danso
Thank you for posting this...surgery is one of the few professions that I
think about, and then think, "Nope, no way, not even in the wildest dreams in
an alternative universe, that I could ever be a surgeon"...but I get the sense
that so much pride is tied up into the skill of a surgeon, such that
mechanical ability and intuition are almost inextricable. I have no problem
with the assertion that a human expert is needed to make decisions as the cuts
are being made. But it's astonishing to me that so much of the success of
surgery relies on a near-superhuman ability of muscle control and focus, an
ability that surely declines with age, even as the surgeon's wisdom and
experience grows. I would love to read more about "autopilot"-type advances in
medicine (though too much of the coverage focuses on, "Will robots replace
your doctor?" rather than man-and-machine working together)

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commentnull
I liked where he had to track down one patient because he had left the keys to
the summer condo inside after they fell in during the operation! Makes you
think...

~~~
dattard21
Dick! - you obviously haven't had family who've gone through major life-
threatening operations ... and come out alive.

~~~
commentnull
My name is not Richard, or any abbreviations of it! But yes, I do actually
know people who have have to have subsequent ops, where material was found
from an earlier op. Not as uncommon as you would think, sadly.

