Dr. Thomas Falasca, May 27, 2019 Author of Physician’s Guide to Better Medical Decision Making: Critical Thinking in Medicine
A wrong-patient prostate surgery with serious complications is reported in the Des Moines Register of January 3 & 7, 2019.
Based on a pathology report of prostatic carcinoma, 67-year-old Rickie Huitt had an unnecessary prostatectomy that left him incontinent. The pathology report was correct about the carcinoma, but wrong about the patient. The incident was alternately attributed to a barcode glitch or to human error, which would be more probable and a case of change blindness.
We have described many cases of change blindness in Physician’s Guide; and, the ease with which it occurs suggests that many cases go unnoticed. However, countermeasures to change blindness exist in the forms of alteration of configuration and sequential attention. Perhaps one of these countermeasures could have avoided the medical error that injured Mr. Huitt.