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Operational mini case studies: Medical error
This case appeared in the Guardian on May 21, 2021, reporting on an incident at the Friestadt Clinic in Freistadt, Austria. The case has been adapted here for discussions on healthcare operations management.
An Austrian hospital amputated the wrong leg of a patient, it said on Thursday, blaming human error for what it called a “tragic mistake”.
The elderly patient was suffering from many illnesses, the Freistadt Clinic, in a town of the same name near the Czech border, said in a statement. Previous sicknesses have affected his legs, to the point that his left leg required amputation.
“We are deeply shocked that on Tuesday, 18 May, despite quality assurance standards, the wrong leg of an 82-year-old man … was amputated,” the clinic said. The issue came to light during a bandage change after the operation.
The clinic’s medical director, Norbert Fritsch, made a statement at a news conference:
“We have to find out how this failure, this mistake could happen. I would like to apologise publicly here.”
The patient suffered from issues in both legs, and Austrian news outlet Heute reported that the patient did not initially recognise the mistake because of his illness. It also said the 82-year-old was asked to confirm beforehand, but his articulation was limited, it reported Fritsch saying.
The error appears to have been made shortly before the operation, when the leg that was to be amputated was marked, the clinic said.
“Unfortunately the mistake, in which the right leg was removed instead of the left, occurred as a result of a sequence of unfortunate circumstances,” it said, adding that it was investigating what happened and would review its standards.
The patient has been offered psychological assistance and must still undergo another operation to remove his left leg from mid-thigh.
“The operation is planned shortly,” the clinic said.
Questions for discussion:
- Why is this a quality issue?
- What actions has the hospital taken in response?
- What further action could they take?