Doctor Left Glove Inside Hysterectomy Patient - Learned Technique From DVD In India Weeks Before

Ben_Reilly wrote:Ah, Andy. When will you learn that you can't confuse rare incidents with everyday life? Bless you  ::D:: ::D:: ::D:: 

BigAndy9 wrote:

Ben_Reilly wrote:Ah, Andy. When will you learn that you can't confuse rare incidents with everyday life? Bless you  ::D:: ::D:: ::D:: 

Ben, it doesn't matter how rare an incident is (malpractice within the NHS isn't rare btw) - it's newsworthy and we can discuss it and proclaim our outrage if we want to.

Our glorious NHS.

The envy of the (3rd) world.

BigAndy9 wrote:It does Ben.

You wouldn't know, because you're not British and don't live here.

Don't make a fool of yourself by making statements about the UK.

There are 4.6 million hospital admissions that lead to surgical care every year in England, and 500,000 non-Caesarian births. There are also tens of thousands of other interventional procedures like internal radiology and cardiology catheter procedures that are also classified as “surgical” in terms of never events. So the incidence rate is less than 0.005% or 1 never event in every 20,000 procedures.

Not all never events result in serious harm to patients. Wrong-site surgery incidents, for instance, range from an incision being made in the wrong place at the beginning of surgery then instantly spotted and corrected, to the wrong tooth being removed, to very severe incidents like the wrong limb or organ being operated on. Information breaking down the types of incidents recorded is available on the website.

Ben_Reilly wrote:Yes, but:

There are 4.6 million hospital admissions that lead to surgical care every year in England, and 500,000 non-Caesarian births. There are also tens of thousands of other interventional procedures like internal radiology and cardiology catheter procedures that are also classified as “surgical” in terms of never events. So the incidence rate is less than 0.005% or 1 never event in every 20,000 procedures.

Not all never events result in serious harm to patients. Wrong-site surgery incidents, for instance, range from an incision being made in the wrong place at the beginning of surgery then instantly spotted and corrected, to the wrong tooth being removed, to very severe incidents like the wrong limb or organ being operated on. Information breaking down the types of incidents recorded is available on the website.

Mistakes happen in every hospital, all around the world, every day -- but the chances of them happening to any one given person are basically lottery odds.

Should the NHS crack down on these and try to make fewer of them happen? Of course! But they're never going to be perfect, and using a rare incident to indict an entire institution is hardly fair, is it?

sphinx wrote:

Ben_Reilly wrote:Yes, but:

There are 4.6 million hospital admissions that lead to surgical care every year in England, and 500,000 non-Caesarian births. There are also tens of thousands of other interventional procedures like internal radiology and cardiology catheter procedures that are also classified as “surgical” in terms of never events. So the incidence rate is less than 0.005% or 1 never event in every 20,000 procedures.

Not all never events result in serious harm to patients. Wrong-site surgery incidents, for instance, range from an incision being made in the wrong place at the beginning of surgery then instantly spotted and corrected, to the wrong tooth being removed, to very severe incidents like the wrong limb or organ being operated on. Information breaking down the types of incidents recorded is available on the website.

Mistakes happen in every hospital, all around the world, every day -- but the chances of them happening to any one given person are basically lottery odds.

Should the NHS crack down on these and try to make fewer of them happen? Of course! But they're never going to be perfect, and using a rare incident to indict an entire institution is hardly fair, is it?

Actually I think it is - I nearly became a nurse myself and did a lot of pre nursing study as well as staying in touch through professional journals and I have to ask how the hell this possibly can have happened.

I mean the " did not tell anyone else in the operating theatre what she had done" may not mean much to you, it sounds like a fairly simply little oversight - but to me it is equivalent to a formula one car starting the race without any fuel in it - it is such an unimaginable happening it is beyond comprehension.  

There is no way something like this can possibly happen unless the very institution itself is rotten because the number of  fail safes that would have to fail for this to even be possible is huge - and it reaches right from what training providers and methods are used by said institution right down to the responsibility of the individual team in the operating theatre.

On July 23, 1983 Air Canada Flight 143 was en route to Edmonton from Montreal when something went terribly wrong! A panel light blinked accompanied by a warning buzzer indicated that there was a problem with the left forward fuel pump. The pilot hoped that it had simply failed since normal flight would still be possible. But a few seconds later, his worst fear was confirmed. A second pump in the left wing was also failing. This almost certainly meant that the tanks were running out of fuel while cruising at 26,000 feet! So that we can get to the heart of the problem, I'll tell you that thanks to an incredibily skilled pilot, all 61 passengers and crew survived the crash landing.

So what happened?

The nagging question is: "How in the world does a jet run out of fuel at 26,000 feet?" Firstly, there was no fuel leak or other engine malfunction. The hard truth is that the ground crew simply did not put enough fuel into the plane before it departed. Let's see how this happened!

1. A maintenance worker found that the fuel gauge did not work on ground inspection. He incorrectly assured the pilot that the plane was certified to fly without a functioning fuel gauge if the crew checked the fuel tank levels.

2. Crew members measured the 2 fuel tank levels at 62 cm and 64 cm. This corresponded to 3758 L and 3924 L for a total of 7682 L according to the plane's manual. (Notice that the Canadian government was introducing the metric system nationwide)

3. The ground crew knew that the flight required 22,300 kg of fuel. The problem they faced was with 7,682 L of fuel on the plane, how many more liters were needed to total 22,300 kg of fuel?

4. One crew member informed the other that the "conversion factor" (being the fuel density) was 1.77. THE CRUCIAL FAULT BEING THAT NO ONE EVER INQUIRED ABOUT THE UNITS OF THE CONVERSION FACTOR. So it was calculated that the plane needed an additional 4,917 L of fuel for the flight.

What the ground crew did

7,682 L x 1.77 = 13,597 kg of fuel on board

22,300 kg needed - 13,597 kg on board = 8,703 kg to be added

8,703 kg / 1.77 = 4,916 L of fuel to be added

What caused the problem?

The metric changeover in Canada should have been accompanied by further education on the airline's part. The "conversion factor" of 1.77 was actually the fuel's density in pounds per liter, not kilograms. The fuel's density in kilograms per liter is 0.803.

BigAndy9 wrote:6th March 2014

Our glorious NHS.

The envy of the (3rd) world.


A doctor who left a glove inside a patient has admitted she was using a surgical technique she learned by watching a DVD.


An investigation was carried out by the Royal Derby Hospital after Sharon Birks found the glove inside her body three days after surgery to remove her womb.


It emerged a member of the team involved in the operation decided to use the glove as part of the surgical procedure.

But the female registrar had only learned about the technique on a course she attended in India weeks earlier and from watching a DVD which had discussed it, a report said.


The use of the latex surgical glove, which was supposed to have been removed before the end of the operation, was not an ‘accepted technique’ at the Royal Derby or one used routinely in the UK.


And the report said the registrar, who has not been named, did not tell anyone else in the operating theatre what she had done, which meant the glove was not taken out.

A horrified Mrs Birks, 42, later discovered the glove when she went to the toilet.


Read more: http://www.dailymail.co.uk/health/article-2574838/Doctor-left-glove-inside-patient-admits-using-surgical-technique-learned-watching-DVD-weeks-earlier.html#ixzz2vD9yyhlh

Ben_Reilly wrote:

sphinx wrote:

Actually I think it is - I nearly became a nurse myself and did a lot of pre nursing study as well as staying in touch through professional journals and I have to ask how the hell this possibly can have happened.

I mean the " did not tell anyone else in the operating theatre what she had done" may not mean much to you, it sounds like a fairly simply little oversight - but to me it is equivalent to a formula one car starting the race without any fuel in it - it is such an unimaginable happening it is beyond comprehension.  

There is no way something like this can possibly happen unless the very institution itself is rotten because the number of  fail safes that would have to fail for this to even be possible is huge - and it reaches right from what training providers and methods are used by said institution right down to the responsibility of the individual team in the operating theatre.

On July 23, 1983 Air Canada Flight 143 was en route to Edmonton from Montreal when something went terribly wrong!  A panel light blinked accompanied by a warning buzzer indicated that there was a problem with the left forward fuel pump.  The pilot hoped that it had simply failed since normal flight would still be possible.  But a few seconds later, his worst fear was confirmed.  A second pump in the left wing was also failing.  This almost certainly meant that the tanks were running out of fuel while cruising at 26,000 feet!  So that we can get to the heart of the problem, I'll tell you that thanks to an incredibily skilled pilot, all 61 passengers and crew survived the crash landing.

So what happened?

    The nagging question is: "How in the world does a jet run out of fuel at 26,000 feet?"  Firstly, there was no fuel leak or other engine malfunction.  The hard truth is that the ground crew simply did not put enough fuel into the plane before it departed.  Let's see how this happened!

1.  A maintenance worker found that the fuel gauge did not work on ground inspection.  He incorrectly assured the pilot that the plane was certified to fly without a functioning fuel gauge if the crew checked the fuel tank levels.

2.  Crew members measured the 2 fuel tank levels at 62 cm and 64 cm.  This corresponded to 3758 L and 3924 L for a total of 7682 L according to the plane's manual.  (Notice that the Canadian government was introducing the metric system nationwide)

3.  The ground crew knew that the flight required 22,300 kg of fuel.  The problem they faced was with 7,682 L of fuel on the plane, how many more liters were needed to total 22,300 kg of fuel?

4.  One crew member informed the other that the "conversion factor" (being the fuel density) was 1.77.  THE CRUCIAL FAULT BEING THAT NO ONE EVER INQUIRED ABOUT THE UNITS OF THE CONVERSION FACTOR.  So it was calculated that the plane needed an additional 4,917 L of fuel for the flight.

What the ground crew did

7,682 L x 1.77 = 13,597 kg of fuel on board

22,300 kg needed - 13,597 kg on board = 8,703 kg to be added

8,703 kg / 1.77 = 4,916 L of fuel to be added

What caused the problem?

    The metric changeover in Canada should have been accompanied by further education on the airline's part.  The "conversion factor" of 1.77 was actually the fuel's density in pounds per liter, not kilograms.  The fuel's density in kilograms per liter is 0.803.

http://www.cheresources.com/flightzz.shtml

Sassy wrote:What a sanctamonious load of old piffle.    Of course mistakes are going to happen.   A swab left inside her, which has happened many times, would have been a lot worse.   Using a rubber glove is in fact totally normal during a Total Laparoscopic Hysterectomy

http://books.google.co.uk/books?id=1HNr_0wpnfIC&pg=PA287&lpg=PA287&dq=Using+a+rubber+glove+inside+vagina+during+hysterectomy&source=bl&ots=xKcelJsHdy&sig=IyrWwf3_tkK3RSE7VB86_n422kI&hl=en&sa=X&ei=SuQYU-S0FPPo7Ab4kIGQCQ&ved=0CC8Q6AEwAQ#v=onepage&q=Using%20a%20rubber%20glove%20inside%20vagina%20during%20hysterectomy&f=false

sphinx wrote:

Sassy wrote:What a sanctamonious load of old piffle.    Of course mistakes are going to happen.   A swab left inside her, which has happened many times, would have been a lot worse.   Using a rubber glove is in fact totally normal during a Total Laparoscopic Hysterectomy

http://books.google.co.uk/books?id=1HNr_0wpnfIC&pg=PA287&lpg=PA287&dq=Using+a+rubber+glove+inside+vagina+during+hysterectomy&source=bl&ots=xKcelJsHdy&sig=IyrWwf3_tkK3RSE7VB86_n422kI&hl=en&sa=X&ei=SuQYU-S0FPPo7Ab4kIGQCQ&ved=0CC8Q6AEwAQ#v=onepage&q=Using%20a%20rubber%20glove%20inside%20vagina%20during%20hysterectomy&f=false

Did you not read the story?

That method was not supposed to be used in that hospital - and somehow the person managed to do so without either telling anyone else on the team they were doing it and without the team noticing it.

I mean a swab being left behind has a fairly short trail to the person(s) responsible namely the scrub nurse and possibly circulating nurse - basically the people whose job is the count.

Junior member of team using practice not approved learned from DVD and managing to break basic code of theatre practice and not being noticed doing so by other members of the team is just a bit more worrying.

I mean since when have junior surgeons been learning procedures from DVD?  Since when have they been practising what they learned without first discussing it with their supervising member of staff?  Since when has ANY prospective surgeon ANYWHERE even imagined they can introduce something into the operating field without it being counted in so it can be counted out again (that is why the count is done after all).  Since when has a supervising surgeon failed to pay attention to their junior enough that the junior can introduce something without it being noticed - or if for some reason this doctor was the most senior on the team since when has surgeon assisting managed to remain so oblivious to what is going on a non approved method involving introduction of a foreign body into the operating field can be carried out without them noticing.

Those are just for starters.

Sassy wrote:

sphinx wrote:

Did you not read the story?

That method was not supposed to be used in that hospital - and somehow the person managed to do so without either telling anyone else on the team they were doing it and without the team noticing it.

I mean a swab being left behind has a fairly short trail to the person(s) responsible namely the scrub nurse and possibly circulating nurse - basically the people whose job is the count.

Junior member of team using practice not approved learned from DVD and managing to break basic code of theatre practice and not being noticed doing so by other members of the team is just a bit more worrying.

I mean since when have junior surgeons been learning procedures from DVD?  Since when have they been practising what they learned without first discussing it with their supervising member of staff?  Since when has ANY prospective surgeon ANYWHERE even imagined they can introduce something into the operating field without it being counted in so it can be counted out again (that is why the count is done after all).  Since when has a supervising surgeon failed to pay attention to their junior enough that the junior can introduce something without it being noticed - or if for some reason this doctor was the most senior on the team since when has surgeon assisting managed to remain so oblivious to what is going on a non approved method involving introduction of a foreign body into the operating field can be carried out without them noticing.

Those are just for starters.

Surgeons learn things from DVDs all the time, and by watching ops over a camera link.   You were a nurse and you don't know how difficult it is to see what is going on in a laparoscopic operation?

When I worked at Barts I used to go and watch the ops in the viewing gallery out of interest, and it's difficult enough to see in a normal op.   The surgeon is basically working by touch.

Sassy wrote:

sphinx wrote:

Sassy wrote:What a sanctamonious load of old piffle.    Of course mistakes are going to happen.   A swab left inside her, which has happened many times, would have been a lot worse.   Using a rubber glove is in fact totally normal during a Total Laparoscopic Hysterectomy

http://books.google.co.uk/books?id=1HNr_0wpnfIC&pg=PA287&lpg=PA287&dq=Using+a+rubber+glove+inside+vagina+during+hysterectomy&source=bl&ots=xKcelJsHdy&sig=IyrWwf3_tkK3RSE7VB86_n422kI&hl=en&sa=X&ei=SuQYU-S0FPPo7Ab4kIGQCQ&ved=0CC8Q6AEwAQ#v=onepage&q=Using%20a%20rubber%20glove%20inside%20vagina%20during%20hysterectomy&f=false

Did you not read the story?

That method was not supposed to be used in that hospital - and somehow the person managed to do so without either telling anyone else on the team they were doing it and without the team noticing it.

I mean a swab being left behind has a fairly short trail to the person(s) responsible namely the scrub nurse and possibly circulating nurse - basically the people whose job is the count.

Junior member of team using practice not approved learned from DVD and managing to break basic code of theatre practice and not being noticed doing so by other members of the team is just a bit more worrying.

I mean since when have junior surgeons been learning procedures from DVD?  Since when have they been practising what they learned without first discussing it with their supervising member of staff?  Since when has ANY prospective surgeon ANYWHERE even imagined they can introduce something into the operating field without it being counted in so it can be counted out again (that is why the count is done after all).  Since when has a supervising surgeon failed to pay attention to their junior enough that the junior can introduce something without it being noticed - or if for some reason this doctor was the most senior on the team since when has surgeon assisting managed to remain so oblivious to what is going on a non approved method involving introduction of a foreign body into the operating field can be carried out without them noticing.

Those are just for starters.

Surgeons learn things from DVDs all the time.

Ben_Reilly wrote:

Sassy wrote:

Surgeons learn things from DVDs all the time.

But in the source, it says this DVD was made in India.

In India.

INDIA.

Sassy wrote:

Ben_Reilly wrote:

Sassy wrote:

Surgeons learn things from DVDs all the time.

But in the source, it says this DVD was made in India.

In India.

INDIA.

Yes Ben, India, which has become one of the top countries in the world for medical tourism because of the standards of it's private medical care:

India is in the process of becoming the "Global Health Destination" owing to the following advantages: The cost of medical services in India is almost 30% lower to that in Western countries and the cheapest in South-east Asia.

Language is a major comfort factor that invites so many foreign tourists to visit India for medical and health tourism. India has a large populace of good English speaking doctors, guides and medical staff. This makes it easier for foreigners to relate well to Indian doctors.

Indian hospitals excel in cardiology and cardiothoracic surgery, joint replacements, transplants, cosmetic treatments, dental care, Orthopaedic surgery and more.

The medical services in India include full body pathology, comprehensive physical and gynecological examinations, audiometry, spirometry, Chest X-ray, 12 lead ECG, 2D echo Colour Doppler, gold standard DXA bone densitometry, body fat analysis, coronary risk markers, cancer risk markers, high strength MRI etc.

All medical treatments and investigations are done using the latest, technologically advanced diagnostic equipments.

Indian doctors have got an expertise in performing successful cardiac surgeries, bone marrow transplants, liver transplants, orthopaedic surgeries and other medical treatments. The cost of Infertility treatments in India is almost 1/4th of that in developed nations. The availability of modern assisted reproductive techniques, such as IVF, and a full range of Assisted Reproductive Technology (ART) services have made India the first choice for infertility treatments.

http://www.indiahospitaltour.com/medical-tourism/india.htm

We have many Indian doctors in the NHS.

Ben_Reilly wrote:

Sassy wrote:

Yes Ben, India, which has become one of the top countries in the world for medical tourism because of the standards of it's private medical care:

India is in the process of becoming the "Global Health Destination" owing to the following advantages: The cost of medical services in India is almost 30% lower to that in Western countries and the cheapest in South-east Asia.

Language is a major comfort factor that invites so many foreign tourists to visit India for medical and health tourism. India has a large populace of good English speaking doctors, guides and medical staff. This makes it easier for foreigners to relate well to Indian doctors.

Indian hospitals excel in cardiology and cardiothoracic surgery, joint replacements, transplants, cosmetic treatments, dental care, Orthopaedic surgery and more.

The medical services in India include full body pathology, comprehensive physical and gynecological examinations, audiometry, spirometry, Chest X-ray, 12 lead ECG, 2D echo Colour Doppler, gold standard DXA bone densitometry, body fat analysis, coronary risk markers, cancer risk markers, high strength MRI etc.

All medical treatments and investigations are done using the latest, technologically advanced diagnostic equipments.

Indian doctors have got an expertise in performing successful cardiac surgeries, bone marrow transplants, liver transplants, orthopaedic surgeries and other medical treatments. The cost of Infertility treatments in India is almost 1/4th of that in developed nations. The availability of modern assisted reproductive techniques, such as IVF, and a full range of Assisted Reproductive Technology (ART) services have made India the first choice for infertility treatments.

http://www.indiahospitaltour.com/medical-tourism/india.htm

We have many Indian doctors in the NHS.

Yeah, I was just joking. I have a feeling some people here have a problem with the India thing ... (coughAndycough)

Ben_Reilly wrote:Yes, but:

There are 4.6 million hospital admissions that lead to surgical care every year in England, and 500,000 non-Caesarian births. There are also tens of thousands of other interventional procedures like internal radiology and cardiology catheter procedures that are also classified as “surgical” in terms of never events. So the incidence rate is less than 0.005% or 1 never event in every 20,000 procedures.

Not all never events result in serious harm to patients. Wrong-site surgery incidents, for instance, range from an incision being made in the wrong place at the beginning of surgery then instantly spotted and corrected, to the wrong tooth being removed, to very severe incidents like the wrong limb or organ being operated on. Information breaking down the types of incidents recorded is available on the website.

Mistakes happen in every hospital, all around the world, every day -- but the chances of them happening to any one given person are basically lottery odds.

Should the NHS crack down on these and try to make fewer of them happen? Of course! But they're never going to be perfect, and using a rare incident to indict an entire institution is hardly fair, is it?

BigAndy9 wrote:

Ben_Reilly wrote:Yes, but:



Mistakes happen in every hospital, all around the world, every day -- but the chances of them happening to any one given person are basically lottery odds.

Should the NHS crack down on these and try to make fewer of them happen? Of course! But they're never going to be perfect, and using a rare incident to indict an entire institution is hardly fair, is it?

So something has to have happened more than once for us to discuss it?

Is that a rule Ben?

It's a ridiculous comment.  The incident should never have happened - not even once.

Incidents such as these do happen, lots, in the NHS, and as British citizens we are interested.