not2old

OP, it's 'negligence' and not 'failure of procedure'

Either way "negligent" by any definition is an 'irresponsible f**k up'

Outside of that, human beings are not perfect, so it's the 'always be prepared for the unexpected'.

Almost Canadian

I don't care what some arse covering person has to say, particularly as they appear to be wanting to avoid finding an individual culpable, but appear to have no issue finding the system culpable.

I take it you didn't read what I said carefully enough to realise that Quebec may have a different set of rules to those in the common law world. I am expressing an opinion and not a finding of fact.

However, I can't imagine that such an item was left in a body without someone being negligent something that, in most of the common law world (but for some bizarre reason, not Canada) is known as res ipsa loquitur.

If you are really interested, Google it.

BristolUK

But your opinion is still disagreeing with the results of an investigation that considered information you don't have and that's what you criticise others for doing.

I'd have expected a gracious mea culpa from you.

Almost Canadian

I don't believe I ever criticise people for having an opinion and I can't imagine how such an item could be left in anyone without an individual having screwed up.

I am perfectly fine if others have an opinion that opposes mine.

bats

It seems that surgical instrument retention is something Canada needs to improve on overall coming way down the list of OECD countries. Another link which I've since lost puts Quebec at the bottom of the provinces

https://globalnews.ca/news/3565069/p...bodies-canada/

dave_j

Q. Can any individual be found to be negligent of a particular activity where a written procedure exists describing how such an activity should be undertaken?

A written procedure, designed to trap and correct undesired actions, becomes the target to blame because if it's been followed as written even if followed badly, it should by it's very existence have been designed to trap such errant behaviour and has therefore not been well enough written to fulfill it's purpose.

This is a catchall argument, for example in this case no doubt the procedure said something like 'count evrything in and out' but it clearly didn't work so the procedure should have included a second layer of checking. This is ok until there's a mistake resulting from a failure of the second layer so do we introduce a third etc etc.

So, as long as a worker can demonstrate an attempt to have honestly followed a written procedure can he or she ever be held negligent even, as AC suggests, the action itself is considered outside the range of responsible behaviour?

Almost Canadian

That would very much depend upon who the individual is and how reasonable the written procedure was. For example, a surgeon that relies upon a procedure that goes against his/her training and experience but which was written by someone in HR that has no knowledge of surgical procedure is unlikely to cut it, if the procedure was not good.

In any event, the person that put the article inside the patient will have to explain why they didn't remove it. If someone else should have accounted for it, they will have to explain why they didn't do so. In other words, more than one person may have been negligent.

dave_j

As an outsider I'd be upset if I thought that the surgeon was following guidelines drawn up by the tea lady, surely the issue in this case is a procedural and managerial one, several layers of expertise below the question of which kidney to remove.. and that opens another can of worms entirely.

The issue I'm struggling with is one of a system trying to cope with the knowledge that ordinary people make mistakes. In this case it's a problem of accounting for items that enter an leave a black box. It should be straightforward, a number of items are identified and placed in the box, the same or different individuals take these items some time later from the box and check them off against the list of items that went in.

Clearly not as simple as it seems.

BristolUK

You are willfully missing the point. It's not the different opinion, you have repeatedly been critical of the holding of individual opinion that has questioned a verdict following some kind of hearing.

You even picked me up on it in a reverse situation recently. I can't find it now but here's one I did find on a different thread.
Yet here you are, not having attended any of the investigations, seen no documents and only having minimal faith in media reports and you are confident those in possession of the facts got it wrong.

Shirtback

I think several of us might be missing a, or the, point here. This is NOT a verdict from a *court of law*, it’s the conclusion/report from the hospital’s internal (sorry!) complaints board.

A court of law may well come to a different conclusion (the parameters aren’t at all the same).

However, although madame Dubé has retained a lawyer, it seems she’s very ill & may have other priorities than legal action at the moment .

bats

You are correct, of course it isn't simple. The count in and out should match, it's one of the tenets of OR procedure. Something failed here and I doubt it was one person's fault as in my IMHO that person would have been identified and disciplined in preference to the hospital taking the blame.

The hospital says they followed standard procedure for Quebec and Quebec has a comparatively high incidence of surgical instruments being left behind. Surely that's an indication that their procedures need reviewing.

Even if an individual were at fault it might still not be negligence. Mistakes happen and they happen more often when workers are tired, overworked, rushed, ill., undertrained, It isn't negligence if you've done your best in the circumstances.

BristolUK

Yep...I used terms like investigation, interviews and documents for that very reason.

Almost Canadian

If you say so.