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.
