Rebecca Foley was a middle-aged woman, who
lived most of her life with her husband in Arlington, Texas. Two years ago, her daughter
had twins, so Rebecca started spending more time in Austin to help her daughter and son-in-law
take care of the babies and to help around the house. For years, Rebecca had a problem
with her eyes – she wasn’t able to see close objects clearly, and the problem was getting
worse. One day she tripped on some steps while coming up in dim light, and fell hard. The
next day, Rebecca’s daughter convinced her to make an appointment for an eye exam. Rebecca arrived for her appointment with her
ophthalmologist – an older doctor with a grey beard, Dr. Emmanuel Sullivan. After a series
of tests Dr. Sullivan concluded: “Rebecca, we have some good news and some bad news.”
“Give me the bad news first,” Rebecca replied with a smile. Dr. Sullivan explained
that she had significant myopia or nearsightedness. “But the good news is that you’re a candidate
for laser eye surgery.” He explained that laser eye surgery was a pain-free procedure
that could be done in 15 minutes and offered long-lasting results. Rebecca agreed and Dr.
Sullivan scheduled her for the following Thursday. On Thursday morning, the morning ophthalmology
meeting was more tense than usual. There were two procedure rooms with lasers, and one of
the machines wasn’t working. To accommodate all of the patients, Dr. Sullivan and his
colleague Dr. Mason would have to share the same room. When Rebecca came in for her procedure, she
felt nervous but the procedure was really quick and she took the rest of the day off.
Dr. Sullivan had explained that she might experience some vision problems that day,
but he told her that everything would be normal the following morning. But Rebecca still couldn’t
see well the next day or the day after that. She started to worry and decided to call Dr.
Sullivan to find out what he thought. Dr. Sullivan reassured her that sometimes symptoms
like blurry vision can be a part of the normal healing process, and that in rare cases it
can take a month or two for the vision to fully normalize. He encouraged her to see
him at the end of the month. A month went by and Rebecca still couldn’t
see well. She felt terrible and she worried that she had become a burden for her daughter
who was already struggling with the twins. Rebecca arrived at the hospital and complained
to Dr. Sullivan that her life over the past month was much worse than before the surgery.
“I feel so useless. I can’t see price tags. I can’t watch television. I barely
recognize the time on my watch.” Dr. Sullivan was worried. He went through Rebecca’s files
and discovered that the laser surgery settings were incorrect – they had been set for Dr.
Mason’s patient. Dr. Sullivan told Rebecca what happened and
the conversation left Rebecca feeling furious as well as frightened. She stormed out of
the office and within a few weeks Dr. Sullivan received a letter stating that he was being
sued for the laser surgery procedure he had performed. Now – to rewind this back – let’s imagine
that Dr. Sullivan had carefully checked the laser settings before the procedure. That
could be part of a standard checklist that gets reviewed before any important procedure.
If that had happened, Rebecca’s eyes wouldn’t have gotten damaged, and her vision wouldn’t
have been damaged. The moral: During any medical procedure, it’s important to do a quick
time out to check that all of the machines and equipment are set for the right patient
and the right procedure.