I thought you might like to see a small sampling of the responses Dr. Sands and I received to our email last week about the wrong-side surgery event. I think they say a lot about the values of the people who work in this hospital.
Well said. I think the decision to share this with the whole community was a courageous one for the people involved but definitely the right thing to do.
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Thank you for keeping us aware.
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Thanks for being so honest with us. It reminds me to never hurry and take my time. I loved the care I received when I was a patient here myself.
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I've read and understand. Thank you.
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I just want to say that I appreciate and respect this incident being shared with the BIDMC Community. I think it is valuable to all employees providing patient care. Thank you.
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Well said.
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Wow. What a horror. I wrote a thank you note to the hand clinic; because all three of my surgeries were done on the correct wrist, hand or finger. Dr. Day initialed me, as did Dr. Upton. It was almost comical how many times they checked to see if I knew what was supposed to happen as they did. But I appreciated it. They must have been so upset. Thank God a limb wasn't taken.
But the surgical staff as a whole was so kind, so committed with even with my non-life threatening surgeries, I was blown away. I think it's beautiful what you said, we also are judged by how we handle the failures, and as a hospital who used to house Dr. Herbert Benson, "a mini" (a short time out, or meditation) would be a great part of the procedure prior to "digging in" if you will.
Thank you for communicating, as always.
It’s really terrific to see the support of so many employees and commenters here. I agree completely that the way BIDMC has handled this medical mistake has been exemplary. And the SPIRIT campaign continues to show how little things can have a huge impact on patient care and employee satisfaction.
ReplyDeleteHowever, it seems that the people who are so supportive are clearly people who are already thoughtful, insightful, and humble about themselves and their work. Do you have any tips for reaching the arrogant, cynical, or apathetic people who aren’t willing to think critically about system improvement? How do you find them and, more importantly, how do you convince them to participate in the process? Is it discouraging to know that these folks may never be "on board"?
Again, as I commented on your earlier post, I applaud your and your hospital's transparent approach to this unfortunate event.
ReplyDeleteI do think that in addition to focusing on the particulars of this case, we all need to think about why your hospital environment, and most health care environments, are so "hectic," leading to "distracted" practitioners. (Something that is glaringly obvious in the out-patient internal medicine context in which I practice.)
Thus, see this post by Bob Wachter, about the trade-off between safety and economic productivity:
http://www.thehealthcareblog.com/the_health_care_blog/2008/07/another-case--1.html
It is clearly economic pressure that pushes health care professionals to see more patients in more time (to generate more fees for specific services.)
Undoubtably some of that pressure comes from the desires of the health care professionals to earn more money. But a lot also comes from the need to support an ever growing health care bureaucracy, and the ever growing remuneration of health care managers. (Mr Levy probably being a notable exception to the latter.)
The SPIRIT program appears to prepare the staff for thinking about the big changes that are needed ahead. The kind of system-wide changes demanded by wrong site surgery, and echoed in the experience of industry (e.g. Shell CEO posting). But where are the physician leaders in this? Are they prepared to change the way they lead their own departments? Is safety moving up the SPIRIT chain? Are we doing risk management or maximizing safety?
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