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Learning From Mistakes

Tue, 12/01/2009 - 2:26pm
Amanda McGowan, Editor
Like many of you, I often attend industry meetings and trade shows to learn about the latest surgical technology and stay up-to-date with what is going on in the operating room (OR). This is crucial in my work because unlike you I am not in an OR every day, seeing first-hand the successes and failures of the next great advancements in surgery. These events are how I get that glimpse into the OR.

Like many of you, I often attend industry meetings and trade shows to learn about the latest surgical technology and stay up-to-date with what is going on in the operating room (OR). This is crucial in my work because unlike you I am not in an OR every day, seeing first-hand the successes and failures of the next great advancements in surgery. These events are how I get that glimpse into the OR.

A few weeks ago, I attended AAGL, where I experienced one of the greatest learning tools available.

I was attending a post-graduate course on robotics. Of the four-hour course, about three of the hours were dedicated to various surgeons who had vast experience with robotics speaking about their tremendous successes in the realm of surgical robotics.

They offered “tips and tricks” to getting started in robotics, discussed the great advantages using this technology can offer surgeons and their patients, and showed video of their successful surgeries using the da Vinci system to an audience donning 3D glasses.

The last hour or so, some of the surgeons took the podium a second time. This time, though, they presented video of their not-so-successful surgeries—procedures in which they made mistakes. None of these mistakes were fatal, or risked a patient's life, but they were errors nonetheless.

One surgeon showed video of her operating on what she thought was a certain area in the patient's body, but it actually was another. “You can see why I thought this …” she explained, and then went on to describe what she did to remedy the situation, and ultimately, what she learned from the mistake.

Throughout this, I noticed how intently the audience was watching. No one judged these surgeons on their mistakes. They understood how it happened—they could see it first-hand on the screen. In fact, the room actually seemed to get fuller as the course continued.

It got me thinking about how unusual it was for these surgeons to openly present their mishaps in the OR to a room full of their peers. Yet, this part of the course was arguably the most educational aspect of the all the presentations.
 
The video footage of the obstacles the surgeons faced when embarking on robotics in the OR were the same obstacles their peers in the audience would (if they hadn’t already) face when they left AAGL and went home to their own ORs. Maybe seeing some of these issues on screen would prevent them from making the same mistake on another patient.

Professionals in any field are often wary to admit their mistakes to their peers, whether it be due to pride, embarrassment, fear or any combination of all three. However, we often learn our greatest lessons from the mistakes we make. So when we talk about educating ourselves, and each other, it’s foolish to keep these mistakes a secret. Isn’t it better that a number of surgeons learn from one’s mistake, rather than all those surgeons making the same mistake on each of their patients?

I learned from the surgeons who presented their experiences—both good and bad—that day. I can only imagine how educational that segment of the course was for the surgeons in the audience, and how grateful they—and their patients—are to the surgeons willing to let their guard down and allow their peers to learn from their mistakes.

Have you learned for mistakes you, or your peers, have made? Tell me about it at amanda.mcgowan@advantagmedia.com

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