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.