#IHI09 Following a wrong side surgery a year-and-a-half ago, an interdisciplinary team of our staff revamped our pre-surgical protocol and developed training materials for all OR staff. Here is a sequence of excerpts of recent emails on the topic.
Please rest assured that this doctor is in a distinct minority, at least in our hospital. Unfortunately, I heard reports at the IHI National Forum from people in other hospitals that his view remains all too common elsewhere.
Surgeons and residents,
Dr. Hurst (Acting Chair of Surgery) and I wanted to let you know you must complete this training module. All OR users must do this. . . .
Please click on the link below to go through the module and do the few questions required. Your completion will be recorded in performance manager, but if necessary send your verification e-mail to your supervisor so they can make sure you have been credited with completion. It is required of all attendings and residents using the operating rooms.
This is an important issue for the institution, as it was one of the corrective actions created when we had the wrong site surgery a while back. . . .
I am sending this out today, as there is a proposal being forwarded to the OR Executive Committee to block OR scheduling and resident access to the ORs until the module is completed. In so doing it is hoped we will have significant compliance. . . .
Thanks in advance for your help with this. If at all possible do it today.
Don Moorman, Vice Chair
Reply from one surgeon, sent (probably in error) to the entire mailing list!
I realize you are only the messenger, but in my humble opinion, this is the classic example of “the tail waging the dog”. Because some goofball operated on the wrong side, we now must all engage in this annoying practice every time we operate. It’s that kind of world, I guess. Too bad!
Response from Doug Hanto, Chief of the Transplantation Division, also sent to the entire mailing list:
I can guarantee you that every surgeon who has operated on the wrong side or left a lap or instrument in a patient never thought it could ever happen to them. These procedures are designed to protect patients from errors that even with the best intentions can happen to the best of us unless we are extra vigilant and have policies and procedures like this in place. . . .