Some situations seem to be impossible, but sometimes they occur, according to the Reason model, when there is an “alignment” of latent conditions. This is an incredible but real story. A 62-year-old man was scheduled to undergo surgery for an inguinal hernia.
Two weeks before the intervention he received the notification for surgery. He opened the envelope and read: Mr. José García. Date of intervention: 1 March. Intervention: Bilateral amputation of the distal lower limbs. The patient was astonished and he complained to the health center. ANALYSIS: In this case there was an administrative error that could have resulted in a medical error. A surgical amputation is such an important procedure that requires always warning signals. COMMENTS: A surgical amputation is a high-risk operation in surgery, not only because of the physical and psychological impact, but also because of the high possibility of error that underlies it. This intervention requires then, a high level of alertness and an exhaustive and quality checklist procedure. The role of the doctor and nurse is crucial, first to identify the patient, second in the verification of the procedure to be performed and in explaining it to the patient. It could be mandatory to do a second check to confirm all the details. And of course: writing the word “Amputation” should not be a simple administrative procedure, but always a medical act.