Follow-up to "never" event

Some of you have inquired what our follow-up has been to the wrong side surgery that took place in July. Here is an email that went out to the staff today on that topic, plus another case involving an impaired physician.

To: BIDMC Community
From: Kenneth Sands, MD, Senior Vice President of Health Care Quality
Subject: Updates after Summer Incidents

Over the summer, BIDMC experienced two troubling incidents that received considerable attention, and rightly so. The first was a “never event” (in this case, a wrong site surgery) and the second involved an impaired physician.

We have recently received the results of the investigations by the Massachusetts Department of Public Health into both cases. As always, we fully cooperated with DPH as they reviewed all our documentation and interviewed key staff on-site. We wanted to share with you a summary of what DPH said, and what improvements we have made in light of these cases:

1. In the case of the wrong site surgery, the DPH investigator concluded that BIDMC acted appropriately in reporting the event, discussing the error with the patient and apologizing to her.

The investigator also noted that BIDMC has initiated a corrective action plan that places ultimate responsibility for calling a “time-out” prior to surgery directly on the surgeon who will make the first incision. But the basic principle remains that while the surgeon always needs to initiate this step, it remains everyone’s responsibility to be sure that all safety protocols are being followed. Specifically, if for whatever reason it appears that the surgeon might neglect to call for the time-out, every other person in the OR is encouraged and empowered to mention that fact.

Additionally, a revision to the "Correct Site Universal Protocol Policy" (PSM 100-105) requires that “the scrub person will mount/arm the scalpel after the ‘time-out' has been completed.” This creates a “fail safe” that ensures that a surgery cannot go forward without following the proper procedure. Everyone working in the ORs has been informed of and trained in these changes to the policy.

2. In the second case, the DPH investigator determined “invalid” the allegation that BIDMC “failed to ensure quality care” in a surgical procedure performed by a physician who appeared to be impaired. The medical center was, however, cited for record keeping deficiencies in the case. The conclusions came after a thorough review of our documentation and interviews with clinicians associated with the case.

We are currently working together, with helpful advice from our Board of Trustees, on a new policy to strengthen the medical center’s procedures when a doctor or other caregiver is impaired or otherwise unable to perform his or her duties. This includes improvements in training for staff on what to do should they encounter such a situation. We will let you know what we come up with.

These recent events remind us that we need to remain ever vigilant about our everyday commitment to quality and safety. We continue to identify and tackle problems as soon as they arise and create a culture where talking about problems or necessary improvements is embraced.

All of us at BIDMC have been involved in efforts to make the medical center a safer and more welcoming place for patients and families. At the same time, we have set a new standard for transparency in our work – the good, the bad and the learning experiences have been laid out for all to see.

We know how much each of you cares about the medical center and the patients we serve. You have helped make BIDMC an exceptional place – for high quality and compassion. Always keep that in mind and be proud.