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Beth Israel medical teams to take more time outs
By adamg on Sun, 07/06/2008 - 12:25pm
Beth Israel Deaconess Medical Center CEO Paul Levy posts the memo he sent hospitalwide following that incident in which doctors operated on the wrong side of a patient. Apparently, the team failed to do one last "time out" to ensure "right patient, right procedure, right side."
... What a horrifying story. What important lessons. We learned that when teams are busy and distracted, it makes it easier to overlook something. We learned that key safety steps, like the "time out," need to occur every single time, since even one failure can be serious. We learned that serious events rarely relate to the performance of any single person. We learned that we have vulnerabilities that we were not even aware of, and that there are surely others out there.
Actually, we re-learned all these things, because none of these observations are new and all of them apply to the entire work place. ...
But Levy adds that things went right following the mistake - the surgeon reported it immediately when he realized what had happened, hospital quality-care staffers began an immediate investigation, the surgeon and others apologized to the patient and senior medical staff agreed to inform the entire hospital about what had happened.
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Comments
Hmm, maybe that person's marker got used on the wrong person...
I had my arm operated on at BIDMC immediately following an injury. They were going in and repairing arteries and tendons and whatever else is in an arm after my arm got gashed open in an accident. In other words, the paperwork sent over to the ER pretty clearly stated that they were repairing a fresh open wound, and only one of my arms had one of those.
Nonetheless, one of the surgeons got out a marker and he and I had quite a bit of fun writing "wrong arm" and "do not operate" all over the wrong arm, along with "fix me" and similar on the injured arm. Although it was unnecessary in the case of an operation that was being done on a fresh injury, it was helpful in terms of reassuring me that the surgeons were being thorough and weren't in a hurry or anything. It's too bad though that they spent so much time doing it in my case and apparently not enough in this other person's case.
[Obligatory comment here about how during said visit, an operating room nurse told me that my legally married female spouse is not a member of my immediate family. And the emergency room registration person repeatedly referred to her as my "husband" when I was providing my next-of-kin information and repeatedly explained that she's my female spouse. She then listed my spouse as "friend" in the computer. Their surgeons were great, but the other staff were homophobic as usual. This might be somehow related to how they're the only major hospital who doesn't send staff to the state GLBT trainings I regularly attend.]
The state trains lesbians?
The state trains lesbians? In what? And you need a regular refresher? I had no idea it was so complicated.
No wonder these people can't get it "right"
But Levy adds that things went right following the mistake - the surgeon reported it immediately when he realized what had happened, hospital quality-care staffers began an immediate investigation, the surgeon and others apologized to the patient and senior medical staff agreed to inform the entire hospital about what had happened.
"Things went right following the mistake?" I didn't see anything about how things "went right" for the patient.
Christ, how cavalier can you get? Look at the stats for wrong prescriptions, people who get infections, etc. The whole medical profession is full of fuckups!
Read his entire post
His main point was how terrible the mistake was. The "went right" stuff was along the lines of "Yes, we screwed up, but the policies we put in place to deal with mistakes worked."
you're missing the point too
Yeah, it was horrible (duh.) Yeah, an investigation and apology are necessary- we're talking bare minimums.
But again- how did things go "right" for the patient afterwards? When you break a friend's vase, you don't say, "whoops! I broke your vase. I'll conduct a FULL investigation into how this happened, my apologies."
No. You make things right by replacing the vase. So. How is the hospital making things right for the patient?
Sidenote: I was absolutely floored that at ANY time the state paid hospitals for their own mistakes!
Dear anon
I am not a doctor and have only been in this hospital world for a few years, but I have seen enough to learn that the hospitals in this city and elsewhere are full of extremely well intentioned people who are devoted to helping the rest of us deal with illness, trauma, or other health problems. Yet, I have also learned that even well intentioned people make mistakes. You can take the view that you have set forth, that the system is full of ne'er-do-wells, but where does that lead you if you want to make it better?
We believe that exposing the mistakes we make helps future patients by reducing the chance of errors in the future, both at our hospital and at other ones. So, the things that I discuss that "went right" are actually pretty important. I never suggested that they excuse the things that went wrong, though.
As to what we do to make things right with the patient, that is a private matter with the patient. But, we know we have obligations on that front, too.
hiding or exposing is not the only choice
'Coming clean' to the public is a commendable organization policy but insufficient to reduce errors. It is the determination of the cause of the 'medical treatment gone wrong', pertinent contributory factors, and an understanding of how standard safety measures failed that can help reduce the occurrence of future errors, if the lessons are acted upon with improved procedure.
It seems to me, that is the story that must be told if Beth Israels' prospective patients are to be reassured, is the story about how the organization learned from this mistake. And that requires yet another level of transparency.
Of course, we intend to do that.
But it is actually not another level of transparency. It is part of the same approach: To hold ourselves accountable to meeting a standard of care that we all believe in and that our patients expect of us.
(And while rightfully asking us to do that, you could ask the same question of other hospitals in the region, too. All have misses and near-misses. Most are not disclosed, nor are their learning processes.)