Pogo is a 17-year-old emancipated minor with two children. When Pogo was 15, he was in a car accident that left him wheelchair-bound as a paraplegic.
Scenario:
Pogo is a 17-year-old emancipated minor with two children. When Pogo was 15, he was in a car accident that left him wheelchair-bound as a paraplegic. Shortly after Pogo’s accident, his girlfriend Dusty left him, so he moved himself and the kids in with mom and dad. Pogo joined a support group with a group of people spanning different generations who provided lifelong advice to Pogo. The eldest told Pogo that because of his condition, he should consult a doctor about having surgery on an open pressure sore he gained by remaining in the wheelchair. Surgeon Busy, a solo practitioner Surgeon, confirmed that he could do the surgery and explained Polo’s condition and that the post-surgery prognosis was good because of his age. Together, Informed Consent was created.
On the day of the surgery, Surgeon Boggles met Pogo’s mom at the desk with Nurse and explained he would be performing the surgery. Nurse and Surgeon Boggles had been on duty for the last 48 hours, but because they both consumed highly caffeinated drinks, both were alert and seemed able to function. Even so, the Nurse glanced down and didn’t realize that Surgeon Busy was scheduled and not Surgeon Boggles for the surgery. In finishing up the surgery, Surgeon Boggles knew it would take another hour to complete. He felt this was a good opportunity to engage one of the new Resident Surgeons sitting in on the surgery. However, Surgeon Boggles didn’t realize that Resident Sleepy had also been on shift for over 48 hours, which was normal for his residency program. In Post-Op, Pogo complained of pain and redness in the area. Upon further discovery, it was concluded that Resident Sleepy did not follow procedures because he was too tired and misread the checklist, which resulted in a cotton ball left in the wound area.
From the perspective of a healthcare risk manager, what recommendations would you make to ensure this type of error won’t happen again?
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