Antoine, aged 38, turned up at the emergency department complaining of severe pain in his right knee. Examinations revealed a tear in the anterior cruciate ligament of this knee. An operation was scheduled for a month later. Early on 12 October, Antoine was admitted to the intensive care unit due to a lack of available beds on the surgery inpatient ward. He was prepared for his operation and taken to the OR by the intensive care team. In the operating theatre, the surgery takes place without incident. However, at the end of the procedure, the surgeon realises he operated on the patient's left rather than his right knee. An ALARM analysis is a way of identifying the problems and causes throughout an organisation (tasks to be performed, teamwork, organisation of patient records, lack/absence of protocols and procedures).
Date de parution : 03/2019
Thème : Wrong body side
Mots clés : Safe Surgery, wrong body side, teamwork
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