Learning the lessons from medical errors



The comment by Prof. Kirby [1] makes heartening reading. To write about medical errors and the need to learn lessons from them is a welcome trend for which the author and the BJU International should be congratulated. ‘Laterality error’ is one of the most common mistakes in urology, and indeed in any speciality dealing with operations on bilateral organs. Risk management is all about minimising the harmful effects of such errors on the individual victims and in a wider sense, on the patient population in general by ensuring that lessons are learnt and precautions taken to prevent such errors from happening again. We agree that the initiation of most accidents can be identified to a specific unsafe act. Failing to mention the side while booking an operation on a bilateral organ is one such unsafe act. Therefore, operating on the wrong side should be a preventable mistake. All that is needed is a conscious effort on the part of the clinician to identify the side each time an operation on a bilateral organ is contemplated. To promote that consciousness, we propose an audit to determine the consistency with which laterality is mentioned on documents like clinic letters, waiting list cards, operation notes and discharge summaries. If a deficiency is identified, making recommendations and re-audit at an interval will close the loop.