Dr. Frank Ransom, a well-known and successful surgeon at the Ransom Medical Clinic, is preparing to operate on a patient's right hip. Dr. Ransom has performed this surgery at least 60 times in the last month and has never had any issues with the success of his surgeries. In fact, he has been recognized in his field as the "best of the best" for hip surgeries.

On the morning of his next surgery, the patient arrives and signs the admission forms. Once this has been accomplished, the patient is taken to pre-op where all the necessary actions are taken to prepare them for the surgery.

The patient is then taken to the operating room, and the nurse drapes the left hip. Dr. Ransom arrives, as per the operating room schedule, and commences to work on the patient. As Dr. Ransom is marking and preparing to make the necessary incision, he pauses and thinks. He asks the nurse to look at the notes and tell him which hip is scheduled to be operated on.

The nurse looks at the medical records and the notes, and the nurse tells the doctor that a mistake has been made and the right hip is supposed to be operated on.

Dr. Ransom immediately stops the procedure and cancels the whole operation, as he wants to identify how such a mistake could have occurred.

Based on the scenario, conduct a change analysis, and address the components listed below.

• How would you go about identifying what has changed since the last surgery?
• What questions would you ask? To whom would they be directed?
• What would you look for in documentation?
• What would be your corrective actions to ensure this never happened again?
• Apply a change analysis process to identify root causes.
• Apply the events and causal factors analysis.
• Contrast events and causal factors and change analysis.