"Anytime you hear that someone has left a 12-inch retractor in a patient, you think, `What kind of idiot did that?'"
But what if the surgeon wasn't an idiot - in the same way that not every pilot in a plane crash is an incompetent? That's the question that has medical experts beginning to take an engineer's view of hospitals. Rather than see them as warrens of individual doctors and nurses, the new view posits them as complicated human and mechanical systems with small, undetected flaws that can make mistakes inevitable. To borrow the airline industry's language, it isn't pilot error that causes most mistakes, but subtle system problems instead. Gawande's simulation conforms to a growing interest in finding new ways to reduce medical errors - not by punishing doctors after the fact, but by building more safeguards into the system.
Anesthesia was the first field to institutionalize this viewpoint, and it led to a dramatic decrease in dosing mistakes. Now that kind of systems approach is coming to surgery (and other fields) with all its obviousness. As Gawande remarks in the article:
"For God's sake," he says, "you can't walk out of a bookstore without an alarm going off. How can a patient leave an OR with an instrument inside him?"
Some common-sense solutions, and neat statistics, are found within the paper. Read the whole thing.