Action being discussed by Beth Israel Deaconess Medical Center in Boston
Posted on Oct 20, 2008
It's encouraging to see a well qualified health care professional willing to openly discuss wrong-site, wrong-side, wrong-patient and wrong-procedure surgical mistakes. We take our hat off to him and his staff.
In July of this year (2008) Paul Levy, the President and CEO of Beth Israel Deaconess Medical Center in Boston commented on a surgical event involving operating on the wrong body part. While this is a difficult mistake to discuss it is a necessary one, because not discussing it will not make it go away.
"While respecting the confidentiality of both the patient and caregivers, here are the key facts: It was an elective procedure, involving an excellent team of providers. It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology. The patient is now recovering at home from the injury, which is not life-threatening."
With the realization it can happen to any surgeon and surgical staff at any facility, no one is immune from making this kind of mistake, the staff can now shore up their protocol to avoid any further mistakes of this nature. I take off my hat to them for their candor and honesty.