This is a tough one as everyone has an angle on it, but there are no worse angles than the surgeon and the patient are experiencing by all means. I had commented on a wrong side surgery that had occurred in Worcester that was in the local paper on July 15th. Someone else had commented about how the airline industry compares with check lists, etc. and my take on the situation revolved around what is going on in the immediate environment at the time as that effects everything. In other words using the airline comparison:
“Just one other note from the aviation side of things, they mess up too and when you have a blizzard going on, the crew rushed to meet their schedule, they have mistakes too, as the first officer might have a better overall inspection in 70 degree sunny weather versus below zero weather with a physical inspection of the jet in preparation for flight. Point in case is what’s happening at the time in the environment makes one big difference too on how the checks and balances are done, both aviation and healthcare, thus the real need for a time out to double check and take a deep breath.”
The Worcester hospital stated they had followed procedures with a time out according to the paper, but it was not enough and stated corrective action was being taken, but hospital officials declined to comment beyond the prepared statement. So how transparent was the other hospital and what are they doing?
2 patients, 2 surgeons, 2 hospitals with a similar issue and 2 different environments at the time of surgery. I think the fact that Paul Levy was up front and spoke about the problem was commendable and is soul searching through the blog on this one for suggestions. It’s a tough spot to be in, but by making the events public, perhaps there’s something for everyone of us to learn and think about as well. The surgeon will no doubt have this to live with his own mental torture of the error for a long time and that in itself is more punishment than any administrator or board could dole out in my opinion. BD
A few weeks ago, a surgeon at Beth Israel Deaconess Medical Center operated on the wrong side of a patient. This is a grievous error, one of the so-called “never events” that’s just not supposed to happen anymore. It still does happen though, so what was perhaps most striking about this incident was the openness with which the hospital administration handled the whole thing.