Went for kidney stone surgery, got a leg amputated by mistake

Ever heard of a Swiss cheese model?

Imagine slices of Swiss cheese (it has random different sizes of holes in it) standing upright in a column, separated for an inch or so from each other. The mistake or a failure of a system happens when all the holes are lined in such way so a spaghetti or pencil can find its way to pass.

It demonstrates how failures can NOT be traced back to a single root cause (one hole is not the problem) but a combination of factors (number of holes which aligns one after another, not perfectly but JUST ENOUGH for an accident to happen).

Omission is always a result of MANY participants in a process failing to deliver fully. Someone was just the last one in delivering so they take the blame when in fact EVERYONE involved in a process failed in noticing, acting upon, double checking or communicating something.

There are multiple scary (true) stories of amputation mistakes in hospitals where patients were amputated a leg instead of e.g. having a kidney stone surgery.

Everyone should be operating from their full responsibility and double checking their part of job but also how it fits the OVERALL CONTEXT and QUESTION THE CONTEXT.

Yet, the process owner is you as a hotel owner. It’s you who is responsible for creating systems and training people to use them, as well as how to act in special situations, self correct and check.

There is no use in blaming a specific person but rather investigate the problem, have LESSONS LEARNT and your systems improved through new PROTOCOLS.

Observe, own it, take notes, learn from it and fix it so it doesn’t happen next time. Because if you don’t, it will.

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