A different approach to malpractice

A Facebook friend from New Zealand, Marie Bismark, writes:

I enjoy reading your blog and was greatly impressed with the honesty and openness of your response to the wrong site surgery incident. As always, my first thoughts are with the patient - and I trust that your hospital has found a way to meet the needs of patients who suffer such injuries without needing to engage in adversarial legal proceedings.

I've always felt very lucky to live, and practice medicine in New Zealand, where issues of compensation are dealt with quite separately from issues of professional and organisational accountability. All patients who suffer a treatment injury caused by medical care are eligible for no-fault, government funded, compensation (with no need to prove negligence). Claims are usually decided within a matter of days, and the package of care includes financial compensation as well as free treatment, rehabilitation, home help, childcare, and so on. As part of a separate process, a health ombudsman can inquire into the quality of care that was provided and make recommendations for systems improvement, further staff training etc.

Not likely to happen here, I'd guess, given the political influence of lawyers and a strong desire on the part of many to insist on financial or other punishment as a form of recompense. (A timely coincidence: See the sentence used in the noun example on Wiktionary to help define "recompense".)

Blogs are like muffins

Check out this recent conference, entitled, "The Health Blogosphere: What It Means for Policy Debates and Journalism," sponsored by the Kaiser Family Foundation on July 29. Lots of interesting stuff. But my favorite quote is at minute 54:35 from Tom Rosenstiel, Director of the the Project for Excellence in Journalism:

When I think of blogs, I think blogs are like muffins They range from everything from bran to chocolate cake. They are more of a shape than they are defining a particular kind of content.... They put you in the conversation, and tonally there is a similarity to blogs.... Similarities pretty much end there.

Pump TV

On June 30, I told you about our plans to solve the pump problem using the principles of BIDMC SPIRIT. We decided to document this problem-solving process with a home-made video. Here's the first of these videos, which presents a pretty good description of some of the problems and the perspectives of a lot of people working here. I am betting that those of you who work in other hospitals will watch this and think we filmed it at your place! Stay tuned as we work through this.

Waiting for Labor('s) Day?

Several months ago, I mentioned the large sum of money being spent by the SEIU on political races throughout the country. Now, an editorial in the Wall Street Journal questions the legality of the manner the SEIU is collecting these funds from its members. (By the way, the sum I mentioned was $75 million. The WSJ raises this to $150 million.)

I am not qualified to make a judgment on the legal issues raised by the Journal editorial writer, but I want to raise a related political issue. SEIU concludes one of its publications with the following depiction of the future: SEIU's health care profile -- and power -- will only continue to grow. After we help elect a pro-worker president and stronger pro-worker majorities in Congress, we will take all our energy, idea, organizing strength, grassroots lobbying and political muscle and make it happen. Next year, 2009, we -- all of us -- will make history. We will achieve quality affordable health care for every man, woman, and child in America.

Well written, for sure, but nowhere in the document does the SEIU mention a very specific and important part of its legislative strategy -- to change the federal law to eliminate the right of workers to vote on whether they want to have a union. The so-called Employee Free Choice Act would undo the long-standing practice under the National Labor Relations Act that provides for an election among the workers to decide if they want union representation.

Here is a story by Kevin Drawbaugh from the Washington Post last year, when the bill was considered by Congress. It appears that the two major Presidential candidates disagree about this bill, but thus far, this issue has not received much coverage or commentary. This is perhaps understandable at this stage in the campaign, but it will be very interesting to see the public's reaction if and when the question is raised in debates and elsewhere as the campaign heats up after, er, Labor Day.

BIDMC expansion plan

I can now divulge that there is substance to the rumors about BIDMC expanding its service territory to Alaska. Here's one of our recruits at a sled dog farm, arranging patient transport services that are appropriate in parts of that state.

Caring provides its own reward

A note from a relative of a patient who made special mention of the fact that he would like for this praise to get wide exposure. Here's the story:

This is a simple thank you for the wonderful job done by some pretty special people at your hospital. Forgive me if I don't get all the names right but I think that it is important that these people to be recognized.

My father was admitted Sunday thru the emergency room last in very serious condition. I won't go in to details of what was wrong, you have the records, but he was extremely critical. I was told about this while I was in Florida and called the hospital ER. I was gently told about his status by a nurse (I think Stacey) and reassured that while very serious, he was alive. We spoke at least 5 or 6 times that day, and each time she was patient with my questions and honest in her answers. Finally I spoke to Dr. Sonnerman who was again very truthful about the situation but in a way that really assured me that my father had a chance of surviving and would be transferred up to MICU as soon as possible.

I guess it was Monday that he did get up to ICU and again the level of honesty and compassion from everyone that I spoke with, nurses and doctors was incredible. I think ICU nurses are a special group of people anyway, and the group that worked with my father was great. Nothing is scarier than being out of town, unable to get to the sick one and having to work THROUGH people. The team includes nurses Pat, Kerry, Dr. Adelman and Dr. Lippincott and Dr. Gillman. Each and everyone one of them was really terrific in communicating what was going on. But there are always people on a great team that seem to rise even above everyone else and should be recognized as the best of the best. Those two are Dr. Howell and one of the ICU Nurses -- Stephanie. I say they were the best not because they helped save him (in fact he passed away last night) but because they made the last days of his life incredibly easy for my father and those of us that loved him.

Dr Howell was straightforward and honest in the description of my father's illness and prognosis. It's not easy for anyone, doctor or not, to sit face to face and lay out the facts of the sickness and the possible choices for us to make on treatment (or, in fact, nontreatment). Dr Howell did this clearly and with compassion. And even if not able to take my call when I want in the hospital always returned the call. You can tell great companies by their great management. I guess the same is true in a hospital department. MICU is special.

Now to the one single person that made me feel compelled to write this note -- Stephanie! (Sorry that I don't know her last name but she was my father's ICU nurse the last two days of his life). First of all, she helped ME. I had my father's living will and definitely knew his wishes. Quality of life was the important thing and to be treated to be able to live a little while longer, or to be in bed for months etc. was not what he wanted. But even knowing that, I knew Saturday when I was going to meet Dr. Gillman and tell him what the plan was, it would be very hard for me to say that my father would rather die than to live an unknown time in machines or in pain. But when I spoke to Stephanie in the morning she had already had a conversation with my father, and he had told her in no uncertain terms his wishes. He was lucid and coherent and was able to speak. So when I got to the hospital, my father repeated his wishes of no treatment, no needles no surgery, but he wanted to be as pain-free as possible for the time he had left.

When I saw my father for the last time Sunday morning, he had deteriorated, and it was pretty certain he would pass in the next 24 hours. I left for the trip back to NY. Stephanie called me twice during the day to say he was resting comfortably and they were increasing the pain killers and keeping him off the ventilator longer. When she called me to tell me he had died at 6:12 pm (she called about 10 -15 minutes after that) she was so compassionate and caring that I felt as sorry for her as I felt for me. She only knew my father a couple of days yet seemed to know more about him and care about him dying peacefully than others that had known him for years.

One should never have to go to a hospital as either a patient or visitor. But if one has, to they should be lucky enough to be taken to BIDMC and meet the people that I met last week. I hope they are in some way rewarded and thanked for their work. Thanks.

I take the chance of saying that their reward comes from knowing they were helpful. They have truly felt your thanks. I add mine to you for sharing this story.

More gelato

My soccer buddy Eduardo, founder of Giovanna Gelato, has two more gelato and sorbet tastings this week. I heartily recommend the grapefruit sorbet, but also the orange and lemon sorbet. And, passion fruit and strawberry, too. All made from fresh ingedients. But then, too, there are the gelati themselves -- coffee, chocolate, pina colada. Ah, choices in life are very, very difficult.

Today between 4:00 pm and 7:00 pm at:
Kurkman's Market Company
227 Cypress Street
Brookline, MA 02445

Saturday, August 2 between noon to 2:00 pm at:
Volante Farms
1 Central Street
Needham Heights, MA 02494

Changes at Longwood

Two items that are emblematic of the constantly changing landscape in the Longwood area of Boston -- home to BIDMC, the Joslin Diabetes Center, Brigham and Women's Hospital, Dana Farber Cancer Institute, and Children's Hospital Boston -- not to mention several colleges, schools, museums, and religious institutions.

The 1873 brick building is at the corner of Longwood and Brookline Avenues, and I wanted to document its nice detail and placement before it is razed in the coming weeks to make way for a new research building for the Joslin and other tenants. People in the neighborhood knew it mainly as the home of a Rebecca's Cafe, but as its age suggests, it has been a fixture for well over 100 years.

The glass and steel structure is the new Center for Life Sciences, on Blackfan Circle, which will house several hundred thousand square feet of research space for BIDMC, Dana Farber, and Children's and perhaps others. It is built on land previously owned by the Judge Baker Children's Center and BIDMC. You can see in its windows reflections of the Harvard Institutes of Medicine and the HMS New Research Bulding, and just visible in the background is a small portion of Merck's Boston research laboratory. Actually, Blackfan Circle should be renamed, because it no longer ends in a cul-de-sac, but is actually a full-fledged street that nicely divides the superblock bounded by avenues Brookline, Longwood, Louis Pasteur, and the Fenway.

Outer Cape Frogs

More lessons learned from switching sides

On May 16, I posted a letter from one of our staff people that generated many comments. Today, the original author of that letter offered a follow-on comment on that entry, and I re-post it here for you to see.

I am the BIDMC employee that wrote the original email to Paul about "switching sides". My mother died a few weeks ago, and today I went to see my mother's favorite nurses to give her a bracelet that I had given to my mother during one of her hospital stays to "brighten up her hospital jonnie." It was a very emotional moment for me, but she was the person that I thought of every time I looked at that bracelet. This is the nurse had been with us since her diagnosis and had made a poster for my mother to "fight hard" while she was on vacation. She was the nurse who helped move my mother off of her bed sore when her nurse that day said she needed to finish her lunch (truly the minority at BIDMC). This is who I think of when I recollect the people who took care of my mother.

All I can say, is that after a two month stay in a long term care facility, BIDMC is doing a phenomenal job, and their dedication to caring for patients and trying to get better every day at it cannot be challenged. The same issues exist throughout our health care system, but the difference is that BIDMC leadership cares. My mother's long term care facility was for-profit, and although the individual nurses and aides tried very hard to care for her, the resources just did not exist. I compared her nurses to flight attendants as they walked up and down with their medication carts distributing drugs. They had no time to be nurses. In addition, we did not receive any hospice assistance until three days prior to my mother's passing and this was because a family friend knew a hospice nurse; had I requested hospice care, my mother would have been transferred from covered under Medicare to not being covered at all, other than a hospice consultation to the family. What is right about that?

My mother died in peace. I know she is in a better place. This experience had been extremely eye opening for me. I continue (from my first day at BIDMC) to be proud to work here, but will always strive for communication, communication, communication.

A tale of one city

Two illustrative stories about health care in today's Boston Globe, with stories by Kay Lazar and Jeff Krasner. While various interest groups squabble about the perceived zero-sum game of who is going to pay for the costs of the health care in Massachusetts, new entrants to the region find a way to gain market share in a small segment of the sector by delivering services at a lower cost.

The problem with the health care "marketplace" is that it is not a real market. There are so many intermediaries that the usual connection between buyer and seller that we see in other fields does not exist. Thus, the incentives for suppliers (doctors and hospitals) to engage in efficiency improvements and value enhancement are extremely slow to emerge. Also, the incentives for consumers to seek greater quality and lower costs likewise are very weak in this field. (This is aggravated, of course, by the lack of transparency about relative quality of providers.)

Then, we overlay on that the fact that government sponsored programs, Medicare and Medicaid and other state subsidized insurance plans, are ruled by administrative fiat and competing political agendas, and we see that over 40% of the delivery of health care is not subject to market influences at all. One result there is the focus on quick fixes that have headline value (not allowing payment for "never" events, for example) that only cover an infinitesimally small portion of the problem but do not address underlying structural problems. Another result is political battles focused on splitting the pie differently but not making the pie the right size or more tasty.

For those of us in academic medical centers, the result will be a gradual whittling away of financial support for the type of clinical care, research, and education for which we were created. We have already seen it on the research side, with cuts at NIH. I predict the next focus in Congress will be on Medicare funding for graduate medical education (residency training).

I have tried to make the point here and in my public appearances that unless academic medical centers prove their value to society as centers for quality and safety improvement and enhancement of operating efficiency in hospitals, the inevitable political response to our pleas will be, "What have you done for me lately? You are the highest cost portion of the health care system, and yet you display no leadership in modeling the kinds of changes we need for it to be sustainable over time."

Ditto, by the way, for the medical schools. When will the thoughtful deans of our medical schools take on the concept of introducing the science of care delivery as a major focus of the curriculum, so that their faculty and new generations of doctors come to believe that field to be as interesting as the study of disease, diagnosis, and therapies? The opportunity exists for leadership opportunities for those universities that pave the way in this arena.

Then, imagine hospitals and medical schools doing this together! As Arlo Guthrie suggests, "Friends, they may thinks it's a movement."

Absent that commitment, the health care agenda will be set by interest groups who will self-interestedly squabble over the distribution of the pie and/or seek commercial advantage by cream-skimming profitable sectors of the health delivery system. Political officials, meanwhile, will follow the votes in setting legislative and administrative agendas. The major institutions that are the crown jewels of the American medical system and were created solely to serve the public good will be, at best, participants in the squabble, and, at worst, passive observers whose assets and programs and influence are slowly but inevitably diminished.

Bike Fridays in Boston, plus Hub on Wheels

A note I am passing along from the City of Boston's biking czarina, Nicole Freedman:

RIDE INTO WORK WITH A POLICE ESCORT.
July 25 and August 22

WHAT: SAFE, GUIDED CONVOYS WITH POLICE ESCORT Lead by experienced cyclists and escorted by Boston Police, convoys follow a fixed schedule and route and originate at locations throughout metro-Boston. All convoys finish at City Hall Plaza Boston.

FREE BREAKFAST, BIKE EXPO AND MUSIC Whether you ride in with a convoy or ride along, join us at Boston City Hall for free food and fun, courtesy of 100.7 WZLX, Mass Commute, Mass Bike, and all our sponsors.

More information here.

And get ready for this year's Hub on Wheels on September 21. A great day to explore Boston neighborhoods on your bicycle. We are pleased to be sponsors of the event and provide first aid at stations along the route.

Management 101, 201, 301, and 401

I've seen and read lots of business books that ostensibly have significant insights into the role of management, but here in one sentence is the best summary I can think of. It comes from Dr. Stuart Rosenberg, who is CEO of our faculty practice, Harvard Medical Faculty Physicians at BIDMC:

"The only role of management is to create an environment where people left to their own devices and unsupervised are most likely to engage in behavior that advances the goals of the organization."

He elaborates in a second sentence:

"That means that people have the training, equipment, space, motivation, pay, understanding of expectations, sense of fulfillment and joy, and all the other things that will ensure that their behavior, the only thing that counts, is what we desire for the organization."

(Just as a reminder for those unfamiliar with makeup of many academic medical centers, HMFP is a separate corporation from BIDMC (the hospital), and it serves as the employer for the physicians on our faculty. Stuart therefore is a peer to me, the hospital CEO, and the two of us and our organizations must work with a great sense of interdependence and collaboration to create joint success. I feel very lucky to have a partner of his caliber as we carry out our public service mission together.)

A picture is worth . . .

With the ubiquity of picture-taking cellular phones and digital cameras, patients and visitors to our hospital have a new -- and very effective -- tool with which to report problems in the hospital. Here is an email note I received from one of our regular guests and its accompanying photos.

Here are a couple of photos from the radiology changing area suggesting that upkeep could be more professional. The first is locker instructions that have long since seen better days (as a result of which two other patients I overheard were having trouble making the locks work). The second suggests that when somebody mounted a new mirror on the changing room wall, they forgot to wipe its birthmarks off it. :)

BTW, all three radiology people I dealt with today were great.

Please note that it is a violation of our rules to take photos of any people. Actually, strictly speaking, it is against our rules to take photos at all in public and patient care places, unless someone has permission and is accompanied by an appropriate member of our staff. HIPAA makes us very sensitive to the possibility that someone will inadvertently or intentionally take a photograph of a patient and in so doing violate his or her privacy by distributing the picture publicly or privately. But as these photographs indicate, technology has made it virtually impossible to enforce that kind of rule. We therefore depend on people to be very careful with how they use what is easily available to them. In this case, I have to admit that I kind of like what happened. The photographs made the nature of the problem very clear and enabled me to seamlessly pass along the suggestion to our staff.

(Blogger formatting note: I post these columns on the Firefox internet browser, as the formatting of text and pictures seems to work best there. When you view the same post on certain versions of Internet Explorer, there is often a problem with the display of the text nearby the photograph. Sorry about that. I haven't figured out a solution to that problem. And now that Bill Gates has left Microsoft, I have no personal (hah!) connection there to resolve the issue.

Wrong math

I have great respect for Jim Stergios and the Pioneer Institute he heads. The Institute has been an important force in Massachusetts public policy debates for many years. But I think Jim has the wrong policy prescription in an op-ed published in today's Boston Globe.

Citing the higher than expected costs of the Massachusetts Healthcare Reform Act of 2006, Jim proposes that there should be a reduction in payment to Boston Medical Center and Cambridge Health Alliance, the two largest hospital providers of care to the poor in the Boston metropolitan region. To be fair, Jim is not the first to propose this. Over the years, there have been periodic attacks on BMC and CHA for their special payments. Several years ago, for example, many of the community hospitals complained that they were subsidizing these urban safety net facilities.

Beyond ignoring the history of these hospitals in our city and the special role they play in the health care system, Jim's proposal puts the focus of the financial problem in the wrong place.

The reason for the higher than expected costs of Chapter 58 is pretty simple. The costs were underestimated at the start. More people than expected signed up for state-subsidized health insurance. And, lo and behold, once people had insurance, they actually used it for medical care. The actuarial estimates of the dollars per person covered were wrong.

That does not suggest that the Act was ill conceived. Not at all. It was a law designed to provide greater insured access to health care. The theory, which will play out over time, is that people with insurance will make better use of primary care and will have better health over time than when they would wait until they were really sick and show up at emergency rooms. But in the meantime, for example, those poor women who had not had mammograms in 20 years will now have them, and some percentage will be diagnosed with breast cancer and will begin treatment. In short, it is entirely reasonable to expect a bulge in health care costs among the population that previously did not have insurance.

If we want to keep this new system in place, there are only three sources of revenue for these costs: The taxpayers, the insurance companies and through them their subscribers, and the hospitals. None of these have tremendous political support, and there will be interesting political debates and compromises on Beacon Hill as this is figured out. I am afraid, though, that Jim has mistakenly chosen to avoid the first two and then focused his solution on a subset of the last one.

Guide to Just Decisions About Behavior

To follow up on our conversations below about punishment and discipline following medical errors, we have been experimenting with the scale above as a guide. Let me know what you think about it, particularly the gray area in the middle in which case-by-case discretion is employed. (If you click on the image above, your computer will make it larger and you wil be able to read the categories more clearly.)

Did you do this on purpose?

My post below and a similar one of the Wall Street Journal Health Blog have engendered a lot of comments about punishment after medical errors. The discussion is important and is not yet complete. Let's expand on the topic here.

Thanks to Don Berwick from IHI who referred me to a recent article by Dr. Charles Denham, entitled "May I have the envelope please." (Journal of Patient Safety. 2008 Jun;4(2):119-123.) Chuck relates the marvelous approach to error used by Jeannette Ives-Erickson at the Massachusetts General Hospital. When there is a screw-up in nursing, she calls the involved nurse into her office and asks one question: “Did you do this on purpose?” If the nurse answers, “No,” then Jeannette says, “Well then it is my fault.... Errors stem from systems flaws.... I am responsible for creating safe systems."

As Tom Botts mentions below and as Chuck reinforces in his article, "When we push the envelope in health care, senior leaders and many clinician often never know about the adverse events because these events are often hidden and masked by the complexity and fragmentation of care.... We automatically fall in a name-blame-shame cycle citing violated policies and ignore the laws of human performance and our responsibility as leaders."

Turning back to Ives-Erickson, Chuck notes, "In a few short moments with a caregiver after an accident, the leader declares ownership of the systems envelope, and the performance envelope of her caregivers, and creates a healing constructive opportunity to prevent a repeat occurrence."

Recognizing that the comments made on this blog and the WSJ blog may or may not be representative of the general public, I was nonetheless impressed by the degree to which people felt that punishment was an essential part of process improvement. It also occurred to me that the easy path for a hospital administrator in this kind of environment would be to punish the wrong-doer, bolt on a new process, protocol, procedure, or requirement, and declare the problem solved. After all, that shows decisive and timely leadership.

There's only one problem. That doesn't work. Or if does, only for a short time or until a new glitch is uncovered.

Many of the comments show to me the level of dissatisfaction with and anger about the health care system in general, and perhaps also individuals' experience with certain "god-like" physicians. But, if those admittedly understandable emotional reactions guide our approach to process improvement, we will not make the kind of progress we need.

Lee Carter, chairman of the board at Cincinnati Children's Hospital -- a national leader in the quality and safety movement -- put it in elegant, all-American Midwest terms: Transparency depends on TRUST....trust that one can report an error without getting whacked. I absolutely agree with your blog in both the lack of punishment for this event and reserving the right to punish for events in the future. If punishment were to be meted out, it should be spread to everyone in the OR who didn't call for a time-out. The point is that it wasn't only the surgeon's responsibility. This is what we are working very hard to spread throughout Cincinnati Children's and we are making slow progress.

Think about it. One of the national leaders says that his place is making slow progress. Let's learn from that. Let's not let our own impatience with the errors that occur cause us to leap to a type of solution that appears easy and direct but that is fundamentally flawed.

Wellfleet Bay birds

My wife just returned from a digital nature photography course at the MA Audubon Society Wellfleet Bay Wildlife Sanctuary. Included in her now much larger portfolio are the red-winged blackbird and kingfisher seen above.

How did they do that?

The Pharm Animals, a softball team representing the BIDMC pharmacy department, pose in front of "their" team sign on the Green Monster after a softball game at Fenway Park yesterday.

Behind the Green Monster

Ever wondered what it looks like in the space behind the Green Monster at Fenway Park, where the scorekeepers sit? Here's a view through a crack in the wall. Each number weighs about five pounds, so those guys are tired by the end of the game from changing all the scores, not only for the Red Sox game being played, but for every other American League and National League game going on, too.

What about punishment?

During these couple of weeks following our wrong-side surgery, a number of people have asked me if we intend to punish the surgeon in charge of the case, as well as other people in the OR who did not carry out the expected time-out procedure. My initial and immediate reaction has always been, "No, these people have been punished enough by the searing experience of the event. They were devastated by their error and distraught to think that they could have participated in an event that unnecessarily hurt a patient. The surgeon immediately reported the error to his Chief and to me and took all appropriate actions to disclose and apologize to the patient, as well as participate openly and honestly in the case review."

This reaction was supported by one of our trustees, who likewise responded, "God has already taken care of the punishment." But another trustee said that it just didn't feel right that this highly trained physician, "who should have known better," would not be punished. "Wouldn't someone in another field be disciplined for an equivalent error?" this trustee asked.

This is a healthy debate for us to have, but a comment yesterday made me realize that I was over-emphasizing the wrong point (i.e., the doctor's sense of regret) and not clearly enunciating the full reason for my conclusion. The head of our faculty practice put it better than I had: "If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are." I think he is exactly right, and I believe this is the heart of the logic shared by our chiefs of service during their review of the case. Punishment in this situation is more likely to contribute to a culture of people hiding their errors rather than admitting them. And it is only by having a culture in which people freely disclose errors that the hospital as a whole can focus on the human and systemic determinants of those errors. I believe this conclusion is supported by most of the advanced thinkers in this field, but I ask them and others of you to comment on that theory of the case.

But, then we are left with a follow-on question: Under what circumstances does the need to punish someone trump the other concerns about institutional learning and a no-blame environment? Beyond the obvious case in which a doctor or nurse intentionally harms a patient -- where no one would doubt the application of punishment -- I am afraid that the answer is, "It depends."

We had a circumstance a couple of years ago in which a doctor intentionally left the OR to consult on another patient while his first patient was in mid-surgery. His logic was that there was a natural break in the procedure during which a tourniquet had to be released for a period of time to permit a limb to reprofuse, and that there was no risk to the patient by his absence. However, he left no attending physician in the room, only residents -- a clear violation of the rules. No harm whatsoever befell the patient, who in fact was ultimately very grateful to this surgeon for completing a very complicated procedure.

Upon review of this case, our Medical Executive Committee felt that the violation of an important rule was so clear that the surgeon should be penalized, and he was suspended for a period of time and the case was reported to the state licensing board.

A friend today asked me what would distinguish a case like that from the recent one in which our surgeon failed to conduct a time-out before beginning the operation. Honestly, it may have been the fact that a case had recently occurred at another hospital in town, where a surgeon left the OR and did put a patient more at risk, and where the publicity concerning that event was widespread. In short, everyone's sensitivity had been raised. But I think the MEC response had more to do with their conclusion that the surgeon knowingly and intentionally left the room unsupervised, feeling that the rule didn't really need to apply to him in that case.

Is that distinguishable from failing to conduct a time-out before a surgical case? I guess intent should matter. In the more recent case, the surgeon clearly did not intend to skip the time-out. His mind was on other things, and he did it inadvertently. While that is, in great measure, his fault, it also suggests to us hospital leaders that there is a flaw in the training we provide or the procedures we implement. In other words, we participated in this error by not having the wisdom to design a sufficiently fail-safe system that would protect the surgeon (and of course, the patient) from inadvertently missing the time-out.

Please understand that I am not saying this to absolve the surgeon from his responsibility. I am saying that to reiterate the point I make above: We should err on the side of encouraging disclosure and honesty about errors so we can properly do our job to re-design systems of care to reduce the chance of error.

But -- while knowing this may appear to contradict what I just said -- there might be cases in the future that are remarkably similar to the one we just had where we as a management team decide that a punishment should be meted out. It is not clear to me that we can have exact rules, in advance, that would draw the distinction. I think this is one area were we must maintain the right to exercise our discretion depending on the particular circumstances of the case.

As always, your thoughts are welcome.

Monique, live

This is a really good interview by Jeanne Blake with Monique Doyle Spencer about The Courage Muscle on About Health TV. Please watch and listen. Then, buy the book.

MITSS Hope Award

Nominations are now being accepted for the inaugural Medically Induced Trauma Support Services ("MITSS") HOPE Award. This award recognizes those people (medical and non-medical individuals, teams, departments, health care institutions, long term care facilities, community health centers, etc.) who exemplify the mission of MITSS – Supporting Healing and Restoring Hope to those patients, families, and clinicians affected by adverse medical events. The award is being sponsored by Quantros, and the winner will receive a $5,000 cash prize.

Nominations are due by September 1, 2008, and the award will be presented at the MITSS 7th Annual Dinner to be held at the Renaissance Boston Waterfront Hotel on Thursday, November 6th, 2008, from 5:30 to 10 pm.

For more information about the award, or to nominate someone, visit them on the web; call Winnie Tobin at (617) 232-0090 or e-mail wtobin@mitss.org; or, mail to at MITSS, 830 Boylston Street, Suite 206, Boston, MA, 02467.

Our learning process

Now, I want you to see something that is so illustrative of the very points Tom Botts makes below. What follows is an email from one of our best surgeons to his Chief making suggestions on how to avoid the kind of wrong-side surgery we recently had. This surgeon is a wonderful person as well as a fine clinician, and his intentions are noble and thoughtful.

But, read the email and compare it point-to-point with the lessons learned by Tom. I don't in any way mean to be disrespectful of the surgeon's thoughts or efforts, but I have become sensitized to the fact that good intentions can lead us into several organizational and learning traps. This is no reflection on him personally: We are all learning a lot about how teams function and can improve in high-stress and unpredictable environments. This area of expertise is not usually part of our training, whether we studied medicine, economics, history, or art. So, we have to learn it now, on the job.

See how many organizational and learning traps you can detect in this note. At the end, I'll give you a couple that I noticed. See if you agree with mine, and please add your own comments.

I've given some thought to the issue of wrong-side surgery since you presented the matter at last week's meeting, and I have some suggestions. I believe we can strengthen our approach to the problem with only modest extra effort in the OR. I would consider the following changes:

1. "Time Out" is now an oral exercise. I'd add written confirmation. Below is a draft of a form that would be initialed or signed and then kept in the patient's medical record. Most people pay closer attention when required to write something that would be available for subsequent review in the event of a problem.

2. It would be a requirement that the surgeon have his/her patient's medical record in the OR. The surgeon would affirm (in writing) that the operative site marked earlier in the pre-op holding area agrees concerning site and side with (1) the surgeon's office record and (2) the patient's signed consent form.

3. I'd consider making the anesthetist a more involved party. The anesthetist would confirm (in writing) that the site and side affirmed by the surgeon agree with the information in the anesthetist's pre-op records.

New guidelines for managing this sort of problem might best come out of a committee comprised of representatives of key stakeholders in the process: surgeons, nurses, anesthetists, administrators, maybe a trustee, maybe a representative of the public. The committee's chair should be an experienced surgeon. A surgeon would be the person most familiar with how the diverse components of the problem interrelate. Also, the product of the committee's work would have more credibility in the minds of surgeons if they felt this were a surgeon-led effort.

Please forward this to Ken Sands and Paul Levy.

CONFIRMATION OF PRE-OPERATIVE "TIME OUT" CONFERENCE

SURGEON
I affirm:
a) the patient in this operating room is the patient identified by the label on this page;
b) the procedure I will perform is:
c) the SIDE for the procedure is (box) LEFT (box) RIGHT;
d) the procedure and side noted in b) and c) above agree with (1) my pre-operative record and (2) the patient's operative consent form, copies of which are in this room. SITE and SIDE as noted in these records agree with my pre-operative marking on the patient's skin.
Affirmed: (signature or initials, name printed)

ANESTHETIST

I confirm:

a) the patient for whom I am administering anesthesia is the patient identified by the label on this page;
b) the procedure to be performed as recorded on the CONSENT FOR ANESTHESIA is:

c) the SIDE for the procedure recorded on the CONSENT FOR ANESTHESIA is (box) LEFT (box) RIGHT.

Confirmed: (signature, name printed)

CIRCULATING NURSE
I confirm:
a) the patient in this operating room is the patient identified by the label on this page;
b) the procedure to be performed is:
c) the SIDE for the procedure is (box) LEFT (box) RIGHT.
Confirmed: (Signature, name printed)
Date: ________________ Time: ____________

OK, here are my comments. First, note the "bolt-on" nature of the solution, i.e., an add-on type of approach. Replacing single-point failure with dual-point failure might be an improvement, but in our recent event no one exercised their prerogative and obligation to ask about the timeout. We know from other settings that filling out a form does not ensure compliance with underlying safety requirements. Forms tend to get signed even when the action to have been taken was not. We need a solution that creates an expectation of compliance from everyone in the room, and freedom to point out a lack of compliance by any other member of the team.

How about this? "The committee's chair should be an experienced surgeon. A surgeon would be the person most familiar with how the diverse components of the problem interrelate." I think this could lead us awry. Every person in (and indeed outside of) the operating room has an important and unique view of how things interrelate. Instead of establishing a surgeon as chair of the committee, perhaps there should be a more neutral facilitator, part of whose job is to make sure that all those viewpoints are taken into account. Also, I wonder if a committee or task-force approach to this kind of issue is the way to go or whether a more broadly based community of people should be involved.

Your turn! Teach me and this surgeon what you have learned.

Being Human - Why do we do what we do?

Another slide from Tom Botts, in which he elegantly summarizes things people do in organizations while they try to operate safely, efficiently and sensibly. Next to each is the "code" for what each one actually means.

Normalizing ----> Always been there, now invisible
Distancing ----> Them, not me
Economizing ----> False efficiency
Discounting ----> Belief over evidence
Coping ----> Doing the best I can
Obscuring ----> Vague communication easier
Learning ----> Always optional

Look familiar? We've seen similar, but more humorous representations, in Scott Adams' Dilbert cartoons. Here's one example, relative to the "Learning" and/or "Discounting" points:

Asok asks, "Wally, how do you keep up with all the changes in technology?"

"Chasing knowledge is a fools game, Asok," replies Wally. Continuing on, he says, "I use experience to answer questions without the burden of knowledge. Observe."

Lessons from "never" events: Mental model shifts

In a post below, I mention some lessons from Tom Botts at Royal Dutch Shell that he and his senior team learned after a serious accident on one of their drilling rigs, lessons that made them rethink their approach to safety. Since then, I've had a chance to exchange a few emails with Tom, and he was very kind to send me an annotated version of major insights resulting from his experience. I post it below. I think there are lessons for all of us here at BIDMC and in other hospitals, as well. They are especially pertinent here as we follow up from our "never event", the wrong-side surgery, and as other hospitals watch and learn from our experience.

As we work through how to improve ourselves, Tom's insights offer guidance and warnings. They are quite potent. I am particularly attuned, though, to Number 5, as that is the usual response when something goes wrong; i.e., "bolting on" a new rule or procedure, which then creates a new layer of error-producing problems of its own.

Tom’s mental model shifts as a result of the Brent Bravo fatalities

1. Good results may not reflect underlying performance
Just before the incident, the Brent Bravo platform’s safety and operating performance was very good, as measured by our normal key performance indicators. The operating performance dashboard which listed ‘traffic lights’ for all of our key performance indicators was mostly green, which gave the appearance of an operation in control and performing well. Key question: Do the metrics I am looking at really indicate the underlying performance? Or are they giving me false comfort?

2. Challenge the green, and support the red
Related to 1. above. If on measurement dashboards, we focus on challenging red lights and praising green lights, pretty soon all the traffic lights will be green. Key question: Are the green lights really green? Am I in too much of a hurry to ‘fix’ the red lights, instead of really trying to understand what they are telling me?

3. At the level of rhetoric, there are no dilemmas
It’s easy for senior leaders to stand up and claim “safety is our most important priority—I do not want you to compromise safety”. And then we leave the people on the shop floor to deal with all the dilemmas of cost, schedule, production, etc. Key question: How do I acknowledge and help people work through the dilemmas they face every day? Or do I leave it up to them to grapple with the tough choices?

4. Lurking in the wall of noise are critical messages
During times of change, there will inevitably be a lot of feedback expressing concern over the change. A key for senior leaders is to resist the urge to dismiss the “noise” and chalk it up to “they just don’t want to change”. Key question: How do I really try to understand the concerns that people have and use that to deliver an even better product? Do I effectively play back the concern so people feel they have been heard?

5. Bolting on best practices may make the system worse
We love to identify and apply best practices. We tell our people to stop reinventing the wheel and find someone who has already solved the problem. Nothing wrong with that, but adding stuff onto the system without fully understanding the system impacts can result in worse performance, not better. Key question: Have I fully considered the unintended impact of applying this “best practice” change to my system?

6. The operations professionals may not see it either
As a senior leader, I assumed the professionals on the shop floor would have the knowledge and the empowerment to stop operations if they felt it was unsafe. We have developed incredibly complex systems, and it’s hard for even the experienced professionals to know if they are operating “outside the envelope” or not. Key question: Do the people at the shop floor making the day to day decisions have the competences and deep understanding of the system they are operating to know when to say ‘STOP’?

7. I’m enrolling somebody in something every minute
We know, as senior leaders, that all eyes are on us and it’s especially important our messages are consistent and well thought through. But we aren’t enrolling people only when we are giving speeches or making presentations. We enrol people with every word and action. Key question: What do I do at the coffee pot, or in idle chatter with staff, or when I think I’m having a private conversation that may enrol people in something different than my “public” messages?

8. A system full of well intended, competent people working world class systems trying their best to meet expectations can produce fatalities
Probably the most profound learning for me. In the Brent Bravo story, there were no obvious ‘villains’, but rather a number of causal patterns that came together to produce a tragedy. The whole point of Deep Learning for each of my senior leaders and me was to be able to see ourselves in the system and what causal patterns we could have been able to break (if we had a better appreciation for the unintended consequences of our many well intended decisions). Key questions: Am I asking the right questions? Am I curious enough?

When your child is smarter than you . . .

It can be both fun and traumatic when you get to the time of life when your children finish college. Here's a portion of a note from a fellow MIT alum, about his daughter who graduated from the 'Tute this year:

I've learned to live with an unfamiliar combination of pride and envy at having offspring at MIT with higher grades than I got. Then to top it off, after commencement I asked her whether she was looking forward to the end of MIT academic stress. Her damned answer was, "I didn't have all that much stress." But of course she missed out on the valuable networking opportunity of periodic contact with the Committee on Academic Performance.*

*(The disciplinary committee you get to visit when your grades become substandard.)

Cape Cod Sealife

A few pictures from a course I took at the Mass. Audubon Society's Wellfleet Bay Wildlife Sanctuary this past week. Excellent instruction by Sanctuary Director Bob Prescott, guest instructors Don Lewis and Sue Wieber Nourse, and naturalist Dennis Murley. Top to bottom: Measuring and tagging horseshoe crabs; Hemigrapsus sanguineus (Asian shore crab); Dark fingered (or dark tip) mud crabs; Calico crab; 10x magnification of calico crab leg shortly after larval stage; Squid egg sacks washed up on beach; Squid eggs at 10x magnification (note the eyes!); Diamondback terrapin.

Thoughts from the staff

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.

SPIRIT List

I know this might not seem as serious as the posts below about wrong-side surgery, but we have made good progress with a lot of call-outs through BIDMC SPIRIT. Some of these may seem somewhat trivial to you, but please remember that fixing even a "minor" item that takes up the time of a nurse or other caregiver creates more time to actually be with patients, improving the quality of care and reducing the chance of errors -- not to mention improving the work environment for that person and many others, too. Remember, too, that these resulted from real people on the floors calling out problems that previously would have resulted in perpetual work-arounds. I think this is good stuff.

So, here's just a running a list from the last several weeks:

The abandoned bikes outside the Farr building have been removed, freeing up spaces for employees to leave their bikes.

It is now easier to find precaution gowns in the ED.

BIDMC’s evening shuttle has expanded its service to provide transportation to Ruggles Station upon request between 9pm and 11:30pm.

The many incorrectly functioning aspects of the mobile computing unit used in the Trauma SICU have been fixed.

Several new documents have been posted to the SPIRIT site to assist with discussions about SPIRIT and its best use. Take a look under “Reference Documents.”

Chair alarms on Farr 9 are easier to track.

CC6A no longer runs out of menus for patients.

Surgical residents can respond to trauma team pages more quickly now by exiting the Palmer and Baker call rooms through doors previously locked at night.

Clinical staff no longer need to hunt around as much for missing suction set-ups on 11 Reisman.

A bathroom on Palmer 2 has reappeared (actually, just the sign had disappeared, but some staff did not know there was a bathroom there).

Nurses and respiratory therapists in the MICU 7 no longer have to tend to ventilator false alarms as often; an equipment default has been fixed.

Patient confidentiality is better assured in certain Dermatology exam rooms now that shredders have been placed in them.

Omnicell restocking on Farr 5 happens at a time more convenient for nurses and for distribution of morning meds.

There is a new process for completing updates to the OMR dictionary—new medications will be recognized more frequently.

CVICU staff no longer have to hunt around for a wheelchair; there is a designated wheelchair and space to store it.

Inpatient RNs have read access to webOMR.

The SPIRIT log has a built-in search function; please use it to gain insight into call-outs that might bear similarities to yours.

The Patient Profile on POE now lists the need for an interpreter when necessary so all care providers are aware of it.

The Farr 7 breakroom no longer receives calls for Psychiatry.

Incorrect instructions for patients scheduled for ambulatory surgery have been updated to include correct check-in location.

There is now a streamlined system for repairing patient call lights promptly on Farr 9.

Patients requiring an MRI or CT are no longer delayed by IV access needs.

New measures are in place to help prevent inadvertent activation of the code center disaster recording.

New signage is helping visitors to the Trauma SICU find the correct waiting room and prompt assistance much more easily.

Patients miss far fewer nuclear bone scan appointments because they now receive appointment reminders.

Patient phone jacks no longer get pulled from the wall on Reisman 11.

Staff in the ED now spend less time looking for tubes to send to the Blood Bank or STAT Lab.

Laptops on Farr 6 no longer need to be rebooted before use.

West Campus MRI techs are more easily and reliably reached via pager.

Vital sign log sheets will now be reinforced to prevent ripping and loss.

Sharps bins on Shapiro 9 and the PACU are being emptied on a schedule more aligned with their actual use.

The Deaconess 2 house staff lounge now has a speaker for broadcasting Code Blue signals.

Lunch is ready for ED patients when they need it.

Nurses on Farr 7 can find a pulse oximeter when they need one.

On 12 Reisman, blood pressure cuffs and parts are better organized and stored.

East Campus CT Techs now have a printer in their immediate workspace.

A better plan is now in place to supply the SICU A&B with enough pillows.

Employees should no longer receive a bill for care following an occupational exposure.

The Dermatology Unit now has a new system to maintain adequate supplies of essential medical items.

Discharge medication lists are now simpler and easier to understand.

Accounts Payable has a new mailbox for invoices to streamline processing.

A change of pace

Early morning views of local mushrooms after my bike ride today. It's been hot and humid here, accounting for the little ones in the grass, but the big one (that's my size 13 shoe next to it) grows out of the same tree root every year, accompanied by three others of the same size. I am sure that our CIO-mycologist, John Halamka, who also has a relevant post today, can identify them. Right, John?

A lesson from Tom

I have received many thoughtful comments below about our wrong-side surgical error, but there is one that deserves some special attention. It is from Tom Botts from Royal Dutch Shell, and I repeat it in its entirety here:

Paul: thanks for having the courage and commitment as a senior leader of a large organisation to role model open and honest dialogue when a mistake is made. Surely that is the best way to ensure learning takes place and improve the chances that the same mistake will not be made in the future.

I am a senior executive in the oil and gas industry, and we work incredibly hard to ensure our operations are safe, every day. But sometimes mistakes are made and we have to be aware of systems and behaviours that discourage open and honest dialogue (people fearing there is more to lose than gain by being open). The short term result of transparency is often a lot of second-guessing and finger pointing. But it's important we break through those barriers, as you are doing, and decide to stay focused on the longer term goal of learning and preventing future mistakes.

In my business, we had a tragic incident several years ago where two men lost their lives. We decided to be as open and transparent about the incident as possible and went through a Deep Learning journey, involving hundreds of people, that examined in detail all the root causes that contributed to the accident, and to get a clear picture of the system that produced the fatalities. Even though the two men that were killed could have made better decisions, my senior leadership team and I could find places where we “owned” the system that lead to the tragedy.

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.

Once you take that step of committing to transparency and learning, it sets a high bar and it is very hard (probably impossible) to take it back. This approach has helped make us stronger and more aware of the impact of our daily decisions. I wish you full success in your learning journey and encourage you to stick with it!

While I really appreciate Tom's point about having the courage to disclose errors, he may overstate the fortitude needed to do that. In fact, one could argue that in today's media environment, it has become more or less standard "crisis management" practice to disclose corporate errors. Admittedly, the medicine and the hospital world is slow to adopt that approach, but it is likely to do so more and more.

The real courage is the one shown by Tom and his team: When we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. Please understand the personal context for him, as explained by our mutual friend Jessica Lipnack:

As head of Shell's UK operations at the time, Tom staked his reputation on safety in this very dangerous industry. A massive campaign ensued. You couldn't walk through a vestibule in any of the facilities without seeing a video about safety. There were signs everywhere. From the largest areas of risk - on the rigs - to the smallest - walking down the hall with a hot cup of coffee without a lid on it, people were encouraged to help one another be more safe. I can recall being reprimanded (in a helpful way) a number of times for not holding onto a railing while climbing stairs, this on dry land in a completely stable building, not even on a seaborne vessel.

Then, unbelievably, two young men died on a rig. They'd gone down into what is called a "leg" of the rig without the proper safety equipment. One was 22, the other, perhaps 30 or so. Very young. Completely unnecessary. Despite everything Tom and his safety group had done, despite training, equipment, and extensive conversation.

The one thing I recall Tom saying is this: He was most surprised by his own faulty thinking, that everything he believed about how something like this could happen was plain wrong, that he had false beliefs about learning, and that he couldn't believe that he'd gotten to that point in his life and been so dead wrong. And this is a person who thinks deeply about organizations and how to change them.

I don't believe we have yet gotten to that point here at BIDMC. Sure, we believe in disclosure and transparency. Sure, we have established superb goals for patient quality and safety. Sure, we have instituted an important program to improve the work place and reinforce the value of every person working here. But these are baby steps along this journey.

When I say "we", I mean myself, our clinical Chiefs, and our senior management team. I don't think we are sufficiently self-reflective yet to question our own underlying assumptions and frameworks about how people learn, how bad habits are erased, and how flexible and thoughtful good work habits are created. The standard to which we should be held accountable by our Boards is whether we will grow to learn the lesson presented by Tom and his colleagues. And will we do it fast enough to avoid unnecessary tragedy in this hospital.

The message you hope never to send

An email sent out on Thursday morning. My commentary follows.

Dear BIDMC Community,

This week at BIDMC, a patient was harmed when something happened that never should happen: A procedure was performed on the wrong body part. With the support of all our Chiefs of service, we are sharing this information with the whole organization because there are lessons here for all of us.

While respecting the confidentiality of both the patient and caregivers, here are the key facts: It was an elective procedure, involving an excellent team of providers. It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology. The patient is now recovering at home from the injury, which is not life-threatening.

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. We have already made improvements in our process for side/site marking and procedural time outs; what can you do to apply these lessons to your work?

The strength of an organization is measured not by counting the number of successes, but by its response to failure. We have made an institutional commitment to eliminating harm, and that requires sharing information about cases such as this so that we all have a chance to learn from it. We still have more to learn from this case, and changes that need to be made, and so will be providing more information in the future.

Sincerely,

Kenneth Sands, MD, MPH
Senior Vice President, Health Care Quality

Paul Levy
President and CEO

----

Before I start, I want to refer you to an excellent story summarizing the case written by Stephen Smith at the Boston Globe.

So, here are a few things you might want to know. The things that went wrong are summarized above and simply should not have happened. The test for our place is to figure out how to make the right things happen 100% of the time. As we work on that, I'll keep you informed.

While I feel incredibly badly about the event, I feel good about the actions taken by individuals and groups right afterward. Here are a few things that went right. (1) The surgeon immediately notified me and his chief of service when he realized that the error had happened. This permitted our Health Care Quality staff to quickly and efficiently interview everyone who was in the OR, while memories were fresh, so we could piece together all the relevant events. (2) The surgeon and others apologized promptly and openly to the patient and explained the nature of the error. (3) When all of our Chiefs of service met to review the case, they unanimously agreed that the case was serious enough that the email above should be sent to all of the thousands of people working in the hospital.

I could not say with any certainty that all three of these things would have happened even three years ago, when people would have been a lot more protective and skittish about this kind of disclosure. But the focus of our hospital on improving quality and safety and our emphasis on eliminating preventable harm and on transparency of our clinical results has taken hold in a very strong way. This is a cooperative effort of the clinical and administrative and lay leadership -- and it takes all three groups to make it happen.

On this particular case, though, one of our Board members put it exactly right: "Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The 'culture of safety' has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change."

While we explore lots of ideas, one already in my mind and that of this Board member would be to make a video with the actual people -- doctors, nurses, surgical techs -- who were in the OR at the time to explain what they saw and felt and what they learned from the experience. While they might be in too much distress to do this right now, they might agree over time, and their doing so would create a powerful message at every orientation, at nurses and departmental meetings, and conferences. Of course, if the patient would agree to participate, that would lend even more power to the story.

As noted by the Board member, "The video could pepper in the stories of near misses and other incidents to keep the lesson broad. The narration would guide the audience to consider challenges and accomplishments -- and work ahead. It could be a 20-minute masterpiece, shown at every orientation, nurses meeting, discussed by chiefs, shared at conferences. Transparency as opportunity, social marketing. It would get people talking, and thinking."

Your thoughts and suggestions?

These commenters were not anonymous

What a great document. A superb exposition and argument. And it was signed. They weren't afraid of posting their opinions, even though it put their lives, liberty, and property at risk. What are so many reluctant to own their opinions today?

IN CONGRESS, JULY 4, 1776

The unanimous Declaration of the thirteen united States of America

When in the Course of human events it becomes necessary for one people to dissolve the political bands which have connected them with another and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn that mankind are more disposed to suffer, while evils are sufferable than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security. — Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

He has refused his Assent to Laws, the most wholesome and necessary for the public good.

He has forbidden his Governors to pass Laws of immediate and pressing importance, unless suspended in their operation till his Assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other Laws for the accommodation of large districts of people, unless those people would relinquish the right of Representation in the Legislature, a right inestimable to them and formidable to tyrants only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their Public Records, for the sole purpose of fatiguing them into compliance with his measures.

He has dissolved Representative Houses repeatedly, for opposing with manly firmness his invasions on the rights of the people.

He has refused for a long time, after such dissolutions, to cause others to be elected, whereby the Legislative Powers, incapable of Annihilation, have returned to the People at large for their exercise; the State remaining in the mean time exposed to all the dangers of invasion from without, and convulsions within.

He has endeavoured to prevent the population of these States; for that purpose obstructing the Laws for Naturalization of Foreigners; refusing to pass others to encourage their migrations hither, and raising the conditions of new Appropriations of Lands.

He has obstructed the Administration of Justice by refusing his Assent to Laws for establishing Judiciary Powers.

He has made Judges dependent on his Will alone for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of New Offices, and sent hither swarms of Officers to harass our people and eat out their substance.

He has kept among us, in times of peace, Standing Armies without the Consent of our legislatures.

He has affected to render the Military independent of and superior to the Civil Power.

He has combined with others to subject us to a jurisdiction foreign to our constitution, and unacknowledged by our laws; giving his Assent to their Acts of pretended Legislation:

For quartering large bodies of armed troops among us:

For protecting them, by a mock Trial from punishment for any Murders which they should commit on the Inhabitants of these States:

For cutting off our Trade with all parts of the world:

For imposing Taxes on us without our Consent:

For depriving us in many cases, of the benefit of Trial by Jury:

For transporting us beyond Seas to be tried for pretended offences:

For abolishing the free System of English Laws in a neighbouring Province, establishing therein an Arbitrary government, and enlarging its Boundaries so as to render it at once an example and fit instrument for introducing the same absolute rule into these Colonies

For taking away our Charters, abolishing our most valuable Laws and altering fundamentally the Forms of our Governments:

For suspending our own Legislatures, and declaring themselves invested with power to legislate for us in all cases whatsoever.

He has abdicated Government here, by declaring us out of his Protection and waging War against us.

He has plundered our seas, ravaged our coasts, burnt our towns, and destroyed the lives of our people.

He is at this time transporting large Armies of foreign Mercenaries to compleat the works of death, desolation, and tyranny, already begun with circumstances of Cruelty & Perfidy scarcely paralleled in the most barbarous ages, and totally unworthy the Head of a civilized nation.

He has constrained our fellow Citizens taken Captive on the high Seas to bear Arms against their Country, to become the executioners of their friends and Brethren, or to fall themselves by their Hands.

He has excited domestic insurrections amongst us, and has endeavoured to bring on the inhabitants of our frontiers, the merciless Indian Savages whose known rule of warfare, is an undistinguished destruction of all ages, sexes and conditions.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A Prince, whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a free people.

Nor have We been wanting in attentions to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which would inevitably interrupt our connections and correspondence. They too have been deaf to the voice of justice and of consanguinity. We must, therefore, acquiesce in the necessity, which denounces our Separation, and hold them, as we hold the rest of mankind, Enemies in War, in Peace Friends.

We, therefore, the Representatives of the united States of America, in General Congress, Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these united Colonies are, and of Right ought to be Free and Independent States, that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. — And for the support of this Declaration, with a firm reliance on the protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes, and our sacred Honor.

— John Hancock

New Hampshire:
Josiah Bartlett, William Whipple, Matthew Thornton

Massachusetts:
John Hancock, Samuel Adams, John Adams, Robert Treat Paine, Elbridge Gerry

Rhode Island:
Stephen Hopkins, William Ellery

Connecticut:
Roger Sherman, Samuel Huntington, William Williams, Oliver Wolcott

New York:
William Floyd, Philip Livingston, Francis Lewis, Lewis Morris

New Jersey:
Richard Stockton, John Witherspoon, Francis Hopkinson, John Hart, Abraham Clark

Pennsylvania:
Robert Morris, Benjamin Rush, Benjamin Franklin, John Morton, George Clymer, James Smith, George Taylor, James Wilson, George Ross

Delaware:
Caesar Rodney, George Read, Thomas McKean

Maryland:
Samuel Chase, William Paca, Thomas Stone, Charles Carroll of Carrollton

Virginia:
George Wythe, Richard Henry Lee, Thomas Jefferson, Benjamin Harrison, Thomas Nelson, Jr., Francis Lightfoot Lee, Carter Braxton

North Carolina:
William Hooper, Joseph Hewes, John Penn

South Carolina:
Edward Rutledge, Thomas Heyward, Jr., Thomas Lynch, Jr., Arthur Middleton

Georgia:
Button Gwinnett, Lyman Hall, George Walton