Like anesthesiologists, surgeons also make
errors. One of the commonest errors is
operating on the wrong side. So the wrong
arm, or the wrong leg, the wrong eye. Any
two sided organs can be operated on inappropriately.
Procedures are in place in most operating
rooms that require the surgeon to see the patient before
entry to the operating room, and to mark the area to
be operated upon with a marking pen.
Despite this precaution, wrong sided
surgery persists. And in my own hospital
we had a case, about 3 or 4 months ago,
with a surgeon who is very meticulous and very
conscientious about marking and getting
the right side. He did all that when the patient
was lying supine in the holding area
prior to going into the operating room. When the patient
went into the operating room, she was turned prone
for the surgery and he misidentified the side.
And operated on the wrong foot.
Fortunately, she needed the operation on that foot
anyway, and they had planned to do the one foot
first and then to do this other foot later. So they
just ended up reversing the surgical order.
But it was very, very fortunate that, that in fact
was the case. Surgeons can also
occasionally damage tissues in error during surgery. So, large
blood vessels may be opened with resulting hemorrhage,
or gut may be perforated, with resulting
peritonitis, infection in the abdominal cavity.
These are rare occurrences, but they
persist. And are a constant concern
of surgeons and health care organizations
in general. So in summary,
in this lecture we've talked about a number of emergencies
that can occur in the operating room.
This is by no means a complete list I hate to tell you.
There are many other things that can go wrong. But these
are things that have a direct bearing on Anesthesia or Surgery
and some of them, such as Massive Hemorrhage,
are relatively common. We ended up
by talking about Medical Error,
Iatrogenic disease. These things are
of a very great importance to all
health care providers and we're working
very hard to reduce them. But unfortunately, as
of the moment, we have not completely
eliminated error in our operating rooms.