Saturday, July 05, 2008

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.


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?


Steve Drury said...

Mr. Levy
I was disappointed and saddened to receive your email about this mistake. As a new employee at BIDMC, however, I couldn't be more pleased on how you and the staff have handled this. I agree that the only way to deal with it is to put it out there, for all to see, and to work on it together. The Board member's idea of a video is excellent. Having just finished orientation for new house staff, I think that a video of those members of our community who went through this, shown at orientation, would add weight to the important issues that this error brings up. Your email and your comments here on the blog make me very proud to be a part of the BIDMC team.

Anonymous said...

We had excellent results at my electric utility company with first-person videos both for accidents and near misses -- there is nothing more powerful than the recollection of someone who lived through it.

Anonymous said...

Well done. The words of the Board member are harsh, but I suppose true. I am sure they will be painful for the team to read. I think it is difficult for anyone who has not worked in an OR to understand why lapses like this might occur. That does not excuse them.

I have spent most of the weekend thinking about this and what we can do to change the culture of the OR. It is a high stress place and changing the culture is not easy, but I think this event will have a powerful effect on all of us in the OR similar to the Betsy Lehman chemotherapy death at the DFCI. The challenge is to make the checks and balances automatic, even under the stressful environment that often happens when one is thinking of the complexity of the operation ahead.

Anonymous said...

Clearly this is not an event to be celebrated. On the other hand the reality is it happened. Nothing will change that and choosing whether to hide or reveal any or all aspects of it is reflective of the quality of the organization that sustained the event. BIDMC’s acceptance of the reality and its embracing the need to be open and seek corrective action are to be applauded. Nothing can be done to reverse what happened. Everything can be done to ensure that something similar doesn’t happen again.

I know the above is not news to those of you at BIDMC. I just wanted to articulate my view and reinforce what I believe is the only responsible direction that an institution with BIDMC’s responsibilities can take.

Anonymous said...

This is shocking. What needs to be added to the time out list is "No distractions please"

Anonymous said...

Well, the point is that there are always distractions of one kind or another, so the system needs to be designed to assume that and nonetheless function properly.

Anonymous said...

I am glad that you came out with the error in public. I am sorry it happened in the first place, but I like the way it was handled.

Anonymous said...

I don't think there's a doctor anywhere who hasn't been in this or an analogous situation, or just missed one. My hearts go out to those involved while not, as others commented, excusing it. But the system failed these vulnerable humans this time; I would be interested in why the time out did not occur as per protocol and who is responsible for initiating it. The Board member was right on target and it makes me impressed with your Board!

As for the video, my only comment is that using the actual players may smack of punishment, and the suggestion to appear in it may be seen as pressure. If one could preface it with some statement that "this could have happened to you, so listen closely", that may mitigate the team's feelings, which have to be low as can be right now.


Anonymous said...

I would suggest one more thing to help prevent this in the future – when I had arthroscopic knee surgery, not only initialed in ink the knee to be done (as is done here) but also drew a large “X” in a circle [the universal “not” sign] on the good knee – adding another site for confirmation of where the procedure was to be done. Just a thought.

Anonymous said...

My thoughts on this sad event.

Because the team of doctors are working so hard for everything to be perfect, they need assistance from a protocol ambassador that will check final review before any procedure starts. The ambassador will then give the green light to go ahead with the procedure. This would eliminate a number of errors.

Anonymous said...

I though you might be interested this article: WHO Proposes Checklist to Reduce Surgery Errors, by Richard Knox. I recently heard this story on NPR and when I read the email below, it immediately came to mind.


Anonymous said...

Such errors occur daily in health care. BIDMC's culture of candor and commitment is the beginning of the end of unsafe practices.
A videotape is a good place to start, but more importantly, processes that avoid this error, even when things are hectic, are needed. Industries avoid error by making safe practices easier to follow than unsafe ones.
We all could imagine a number of ways to make it easier for the team to do time outs than not do them, but BIDMC's nurses, scrub techs and surgeons should be charged with the task of designing a system to avoid wrong sided surgery. They more than anyone else understand the nuances to design the best system for themselves. Moreover, this will help heal these committed, hard working professionals, who at this point must feel shame and remorse.

Anonymous said...

Some thoughts:

1. Transparency is easy/cheap when the problems are minor. This is where it's real, not BS.
2. We have very good people, but good people need the right culture to be able to really be their true good selves.
3. The Board member is exactly right.
4. If even a couple/few of them wanted to make a video and would find it meangingful, that would be very, very powerful.

Anonymous said...

Thanks for sharing this lesson,

Your email said.

"Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side."

It should be said, "correct patient, procedure, and side" since "right side" could get confused.

Just sharing from experience.

Anonymous said...

Your public display is an example for the national and city healthcare community. The classic business school example is of the "poisoned Tylenol" from the 1980's and Johnson and Johnson, the company that produced Tylenol reponse to the situation. Being able to admit mistakes, focus on the 'root cause' and/or systems leading to mistakes or near-misses is admirable. However, laying the ground work for the 'front line' staff, clinical members, ancillary staff, patients and families to report and suggest needs for improvement is the true goal. Again, admitting mistakes on the backend is great. However, preventing mistakes is the goal. All of the members of the 'community' need to have a mechanism to provide feedback and close the communication loop. This will encourage further involvement and truly add to the knowledge base in safety science.

Roy M. Poses MD said...

Sorry to hear this story, glad the patient was not seriously hurt, and I applaud the forthright way you have shown light upon this case.

I might add one thing to think about. There are many instances in medicine in which people are distracted and in a hurry because they are coping with unexpected emergencies. Health care is a context in which emergencies can happen at any time.

However, it now seems that most of us in health care are in a big hurry and distracted all the time, whether in the presence of unexpected emergencies or not. Much of this hurry and distraction is not the result of the variability of biology and disease, but of how the health care (non)system had been (mis)constructed.

This might be a good time to step back and think about why we all have to be in such a big hurry and be so distracted so much of the time.

linda pitler said...

The Board member is totally correct. I think the video is a great idea. I do not agree with the anonymous posting above that it would be "punishment". Rather, giving the team the opportunity to tell their story not only would be very powerful for future groups, but healing for them. Not being able to talk about this error is much more harmful -

Anonymous said...

Anon 9:18 has a very good point about which I had forgotten. When charged (as medical laboratory director) with finding a consistent protocol for identifying patients at the time of intraoperative blood transfusion at our hospital, we went through several unsuccessful iterations dreamed up by various administrative levels before we went to the OR nurses themselves. They not only came up with a single method that best suited them, but got the anesthesiologists' buy-in themselves and immediately implemented the system. Several told me later they were vastly relieved to finally have a consistent and safe system. Perhaps anon's good idea would work best.


Anonymous said...

Dear Pat (9:08),

I have to respectfully disagree.

In my view, you have the right sentiment, but the wrong cure. Nobody should need to be appointed to go in to the OR to make sure a time out is done. That is the responsibility of the surgeon, first, and everybody else, too. That happens in the overwhelming majority of cases. It did not here. The goal is to make sure it does. But, if you take away the responsibility from those who should own it, you don't ever get to the result that is needed.

Anonymous said...

Roy (3:47),

Of course I agree with you about the overarching problems in health care, but in the meantime, we can't use those as an excuse, and we need to do our job well regardless. (But I know you know that!)

Anonymous said...

I apologize for the lengthy comment!
Dear Paul,I too am sorry to hear about this unfortunate event and I admire your culture of candor. Many thoughts have gone through my mind about this event and what could have possibly gone wrong in your OR that day. First of all we should remember that after all we are all human beings thus we make mistakes from time to time. That is why we implement procedures like time-out, hand hygiene, or the “bundles” (IHI). These procedures are there to help us provide better and safer care for the patients. The problem is that not everyone sees it that way. For most part they are looked at as mandates and edicts that we need to adhere to because they are required by a regulatory agency or impact P4P, etc. I personally believe that due to the traditional nature of healthcare industry, our culture has not been viewing these procedures and safety measures essential to good patient care, hence not truly embracing them. We get too comfortable with things like surgeries and treat them as “routine”. It is an awfully big deal to take a scalpel and cut into someone’s body. We should never take that lightly, no matter how many surgeries a day we perform. Notice I say “we”. I am not a surgeon but a process and quality improvement specialist in healthcare. I take ownership for what happens in our hospitals. We all should. I see what happens in our ORs as a shared responsibility. Safe surgery is not only the surgeon’s job, even if the surgeons think so. I have learnt that time-out is collaboration amongst the surgeon, the anesthesiologist and the nurse. If your surgeon was having a hectic day on the day of this unfortunate event, where were his OR partners to remind him the need to perform a time-out? Please understand I am not trying to make your team feel worse about what happened that day. This may be an opportunity not just for BIDMC but all of us to look into what happens in our ORs every day. Are the nurses possibly intimidated by the surgeons or do they truly feel empowered to tell the surgeon to stop and perform the time-out? Are the anesthesiologists spread too thin and assigned to 2 or 3 cases at the same time just simply because they are too “expensive”? Do the other folks who float in and around ORs feel a sense of partnership to alert someone that a mistake is about to occur or simply we have taught them that they should stick to doing their own job? These are some of the familiar questions that we should be asking ourselves. In a good manufacturing environment, for most part anyone can stop a production line when they see something going wrong or about to go wrong. Of course they have been trained to “see”. The good news is there are solutions out there. If we learn from the lessons of other industries we can utilize tools and mechanisms to mistake-proof the processes in ORs or elsewhere. I have transitioned to healthcare from manufacturing. To me a process is a process. Like with any other processes, we need to have standard-operating-procedures in our hospitals. We need to utilize mistake-proofing tools. We need to have metrics and publish our performance to keep ourselves on our toes! That is the way to reduce our error rates. Luckily BIDMC is ahead in that game. All the best to your team during this difficult time.

Anonymous said...

An Excellent Damage Control Exercise.!!

Bareing our own chest volutarily and going public took the bite out of the Negative Publicity and pre-empted the Media hounds from tearing-up the BIDMC reputation to shreds.

BUT does it still absolve us of ALL the Legalities??
Even if the Patient does not sue?


The fine print not withstanding, Does the Hospital still bear resposibility & support its Team in case of Financial Penalty being imposed??

Anonymous said...

Yes, the hospital supports its staff.

Putting this in terms of "damage control" totally misses the point and the impetus for why we chose to share the story with the thousands of people who work here.

Anonymous said...

Our hospital mandates that ALL members of the team (MD's, RN's, RRT's, etc) undergo a 4 hour teamwork training program through TeamSTEPPS that discusses failures of teams in medicine, the importance of the safety culture, hierarchical issues and wrong site surgeries to name a few. What is required for BIDMC??

Anonymous said...

Paul--stuff happens, and your reactions are good. However, was BIDMC using the new checklist put together by Atul Gawande's team and WHO? I had a relative in surgery last week and I checked the pre-op activities against the checklist. But of course I wasn't allowed into the OR to ask about the rest. I have no idea if the hospital concerned used it.

Is BIDMC using it? It's been public for 2 weeks. My guess is no...

Anonymous said...

i am going to disagree with you slightly here. x can be the universal sign for no, or x can mark the spot.

i strongly think to avoid confusion it is best to mark only the surgical site and with initials. marking both will lead to confusion, especially among new staff.

Anonymous said...

As a researcher at another hospital, I have been through the bland orientation exercise where you read the manual, check the box that says "I will speak up if I see something going wrong," and escape as quickly as possible back to work. This event is a 'culture of safety' 'call-out,' is it not? Now that you recognize continued vulnerability to put other things before safety, what about incorporating invigorating 'culture of safety' lessons into your SPIRIT program?

Anonymous said...

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 of the same mistake being 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 behavours 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 commiting 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!

Anonymous said...

Here in MN, there was a well-publicized case back in March of the wrong kidney being removed from a patient with kidney cancer.

In this case, the wrong side was misidentified farther upstream, in the patient's chart - and no one caught it until after the pathology report came back.

Last week a report was released on the RCA that was done. Distraction by the urologist while doing his charting was cited as the root cause, although there were a number of other contributing factors.

What this says to me, a layperson, is that the system is incredibly complex. It can come off the rails at any point, so it takes constant mindfulness and a high level of awareness of where things can go wrong.

This isn't addressed in your post, but I'd be curious to know: What was the patient's involvement? Did the patient have a clear understanding ahead of time of the surgical procedure he was supposed to undergo? Was he educated ahead of time about the process and what to expect?

It seems to me that it's a basic part of informed consent that the patient (or a family member who can advocate on the patient's behalf) should know which procedure he's going to have and on which site. And it's the physician's responsibility to make sure the patient understands this.

Going back to the kidney cancer case: It's understandable that once they hear the word "cancer," the patient and family aren't going to hear much else. But it's just so basic to a cancer dx that the patient would be clearly told which kidney was diseased, maybe even have it pointed out on a CT scan. It might take the inconvenience of an extra visit to further discuss the patient's dx... but this communication has to happen, and the physician should not be sending the patient out the door until he/she is satisfied that yes, the patient (or proxy) grasps the dx and an outline of the course of tx. Otherwise how can you possibly claim informed consent? I mean, even after the surgery, the patient and family apparently didn't recognize the incision was on the wrong side.

And if patients and families are educated ahead of time about what to expect, then hopefully they would be more engaged. They would know to expect that a time-out will be conducted and that the surgical site is supposed to be marked with the surgeon's initials. (That's the recommendation in MN; I completely agree that X is just too ambiguous). If the time-out isn't performed, patients should be able to speak up (without retribution!) and say, "Um, excuse me, but don't we need a time out?"

I realize this will take a lot of empowerment and many people are too sick and/or too intimidated to feel very empowered. Literacy is also a huge issue.

But I have this awful mental picture of patients being wheeled into surgery like sheep, or like cans of dog food on an assembly line. "Cut here; cut there; next!" I had a close call with a wrong-site surgery myself, and it would never have been caught if I hadn't been informed ahead of time of the correct site and procedure. I've also been mistaken for the wrong patient, and this wouldn't have been caught either if I hadn't noticed that the questions about my medical hx were off base.

I think health care workers often have the attitude that it takes too much time to talk to patients and anyway, most patients have no clue what's going on, so what's the point? How many health care workers, reading this, have ever rolled their eyes because a patient asked a question, or cut off a family member who was trying to express a concern? This is a dangerous attitude to have.

We are your allies. We are smarter than you think; we notice more than you think. Talk to us. Involve us. We are supposed to be in this together... Right?

I apologize for the length of this post, but I felt some of these things needed to be said.

I applaud your openness; no one learns from mistakes that get swept under the rug.

Anonymous said...

Sorry, don't feel the need to applaud you. What you've done is turned this into a "yay for Paul Levy" scenario. BTW, so did the internal memo accidentally leak to the media by a member of your staff or did you proactively call the Globe on Thursday and say "hey I got a story for you!" Hmmm.... selective transparency, perhaps?

Anonymous said...

No applause is sought or requested. This was a mistake that did not need to happen.

Yes, we sent the Globe and other media the email that went to the staff. By publicizing the incident internally and externally, we hope to make it less likely for mistakes like this to happen in the future -- certainly at our hospital, but perhaps also at others.

What is your proposal if such a thing were to happen again? Don't notify the staff? Don't share it with the media? Appear to be hiding it so that it looks like we do not acknowledge our mistakes? What is your advice on such an incident?

Anonymous said...

As someone who had several emergency surgeries at BIDMC during the past 5 years (including cancer-related), I want to offer the observation that during my stays at BIDMC, I was highly impressed with the calm and orderly process deployed during my own surgeries.

I recall the staff checking, and re-checking who I was, what was being done, and many other details before entering the OR area, upon entry to the OR, and at other points in the process.

The kindness, compassion, thoughtfulness, and yes, thoroughness of all the BIDMC staff pre-op, post-op and during my entire hospital stay will always remain in my memory as a time when I was given the best possible care, and exceedingly well-taken-care of.

The candor and integrity of everyone at BIDMC related to the recent event is truly impressive. These qualities inspire continued confidence in the treatment and care I might receive from the outstanding staff at BIDMC in the future.

I know that I owe my life to the outstanding compassion and skill of BIDMC staff. I offer my profound gratitude to everyone who cared me during my own stays at BIDMC, and I applaud your handling of the recent event.

Anonymous said...

The approach that you, your staff, and your Board took to disclosing this event and your ongoing attempts to learn from it and make changes where necessary, are truly impressive, especially in the dominant culture of "deny and defend." You and your hospital stand as models for other organizations to emulate.

However, I am having trouble understanding the attitude of the providers who have posted so far, including the suggestion for a "time-out police." In your hospital, the "system" had a built-in error-mitigation process, the policy and procedure were known to the OR staff; OK, now what? The OR staff cut corners and neglected the rule. Aren't there any consequences for this? I keep thinking of this analogy: they were licensed to drive their car, they took lessons to learn how to responsibly drive, they learned the state laws and potential violations, they raced through a yellow or red light, and had a crash in the intersection. Don't they get a ticket or have their license suspended? Or does the stop light get moved or removed by an indulgent "system" because they had an "adverse event"? Note, I'm not advocating for "shame and blame" in places where "the system" has let staff down or where top management and the Board don't recognize their role and responsibility for implementing a culture of safety or designing and implementing error-mitigation practices, policies, and procedures.

Can you disclose how you ensure that accountability for violations of known safety practices and procedures (i.e., the "rules of the road") is enforced?

I also have to say that "distraction" is in the eye of the beholder. Once when I was a patient, three nurses came into my room, one of whom was supposed to sedate me before an operation. All three were "distracted" by discussing their private lives for at least 15 minutes in my presence. I never did get that sedation. Wheeled into the operating room, being awake and aware, I was able to hear the OR team being "distracted" by the loud music that was playing, the flirting between the nurses and doctors, and the nurses discussing their private lives or complaining about working conditions among themselves. I understand that this story is anecdotal and not indicative of all hospitals and all OR teams. Still, I wonder how often other patients experience similar "distracted" providers.

Anonymous said...

Anon 1:25,

Yes, the patient had full knowledge of the proposed procedure. The mistakes occurred after the patient was sedated.

Anon 4:23,

Many thanks. Most of the time, we do a really good job!

Anon 8:23,

I don't think the analogy to driving violations is apt. But others may disagree. I am less concerned about imposing sanctions and penalties than I am about learning from mistakes and near-misses. I would rather err on the side of not punishing people in the hope of prompting full and open disclosure. I think most people in this field believe that a blame-free approach to problem solving is most effective.

Of course, there is a line after which disciplinary actions can and have been taken.

Anonymous said...

When I visit your blog, I look for insights and learning about hospital administration. In my work as CLO at an east coast hospital, I look for ways to encourage trust, openness, and reflective practice. All of these are present in your leadership of the response to this terrible tragedy. It's not just mistakes that have to be corrected in our healthcare institutions, but the deficiencies of people and teams to gain knowledge from those errors. Thank you for lighting the way to those precious capabilities.

Anonymous said...

To answer a couple of questions in these comments:

EVERYONE in the BIDMC OR, from the orderlies to the chief of surgery, goes through team training. It is NOT regarded as lip service, but is truly empowering to everyone to speak up if something amiss is noticed. For example, if the medical student (bottom of the totem pole!) notices the scrub tech accidentally breaking sterile technique, he points it out and is thanked for it---no one EVER tells anyone to "mind your own business." There is a "white board" in every single OR on which the patient, the surgery, and the FIRST names of everyone in the room (surgeons, nurses, anesthesiologists) is listed just to facilitate communication among the team. (We are a huge place and no one knows everyone by name.) Every case, every day.

As for Dr. Gawande's "list," we have been doing those things for YEARS. (yawn)

This culture is NOT a "yay for Paul," it is a "yay" for all of us because we are committed to patient safety and because we are proud to work at BIDMC. I am sorry for you for being so cynical.

Anonymous said...

Readers may be interested in the Universal Protocol for time outs at the Joint Commission website at the link below:

To anon 8:23, there is discussion in the patient safety community regarding where to draw the line in a "no-blame" culture. The general idea is that deliberate failure to follow a protocol designed to prevent error, such as circumvention of patient barcoding for medication administration, does not qualify as a "no-blame" error. I would imagine that in this case, forgetting to institute a time out would trigger a root cause analysis as to how this happened; whereas someone saying "this time out protocol is bunk and we're not going to do it" would be treated entirely differently.

Anonymous said...

Anon 11:28;

It's a safe assumption that you work in the OR at BIDMC. (: Understand that when Paul puts something like this out in public (it also appeared on The Health Care Blog), it serves a valuable educational function for the general public, who has little idea of what goes on behind the scenes in hospitals. However, there are a frightening number of people out there who are wholly distrustful of our health care system and everyone in it. So, you are going to get these cynical comments also. All you can do is continue to follow Paul's strategy of complete transparency, in good and bad times, until these people's trust is eventually regained. (That may not happen until everyone in the country is so transparent, including the insurance companies.) That's why you have such a valuable CEO; he is putting his money where his mouth is.

nonlocal MD

Roy M. Poses MD said...

The wrong site procedure was clearly a bad event and an error that should not have happened.

But the hospital and its leadership deserve credit for admitting the error, and having an open, honest discussion of it. This transparent approach is much better than the what is more usual, attempting to keep the whole thing quiet, and for top leadership to avoid blame.

I do want to reiterate my point to Paul Levy. I agree that blaming the larger environment should not get in the way of addressing the immediate problem.

But I urge you all to think about what external pressures there are that make people distracted and make them feel they have to work too fast. Such pressures (except when they occur because of truly unpredictable medical emergencies) should not be simply accepted as inevitable.

Anonymous said...

Very interested in this issue.
I'm an anesthesiologist at a large health care system (believe me, you've heard of us).
I am aware of wrong site surgery/procedure issues that have occurred despite completing proper "site marking" and "time out" procedures.
As I'm sure you know, Mr. Levy, there is data to suggest that the incidence of wrong site surgery has not gone down, and may even have gone up, since the start of the "universal protocol."
There is also data from the surgical literature that suggests site marking and other elements of the universal protocol would not prevent many wrong side issues (eg the kidney story in MN)
My experience, as was mentioned above, is that oftentimes the elements of the universal protocol are seen as pointless "box checking" mandated by the "bean counters". Unfortunately, there are still many in health care (mostly physicians, unfortunately) who don't see much value in anything labeled "quality" or "safety".
While I think many of the comments above about modifications to the system are well intentioned, they miss the point. WHATEVER the system is, it has to be taken seriously by all involved, ESPECIALLY the physician actually performing the procedure.
Until safety and avoidance of error is inculcated in training (by and large, it is not) and it is part of the makeup of a physician (and sadly, at the present time, it is not) the mistakes will continue.
To paraphrase Yogi Berra, culture change is hard, especially when it involves people.
I applaud what you are doing, generally and specifically; there are many of us out here, like you, who work to make medicine more like other industries that have adopted a culture of quality and safety.

e-Patient Dave said...

Very long one here. This hit me hard.

I just spotted this tonight, and in an instant my eyes filled with tears. That's not everyday for me so I thought about why.

What I'm left with is a searing, painful awareness that medicine is practiced by humans, and it hurts when something like this happens. It really hurts.

For one thing, the wrong-side subject is fresh in my mind, because of the Minnesota kidney cancer error in March (they removed the healthy kidney), a year after my own nephrectomy. When the MN one happened, the possibility of such errors was vivid to me: I could imagine having woken to such news. So now, this incident hit me like a nightmare becoming real.

At the same time, I care deeply about what this institution is up to. I've experienced first-hand the care of its best people, and I've experienced programs that I've read about on this blog. So I have a sense of personal relationship with the mortals who chose to go into this field, studied their buns off, got good at it, and work hard - people with homes, families, lives.

So part of my emotional mix was the pain every one of the involved employees must have felt at that moment of realization. Lord, to wake up every day with that knowledge...the polar opposite of what they envisioned when they chose this line of work.

Meanwhile, I'm deeply involved now in the patient empowerment movement on the e-patient blog, raising awareness of patients doing everything in their power to participate in their care. Week after week we hear stories of patients who provide support to others, other stories of patients who got wrong diagnoses, and more. Interviews with these e-patients have left me caring even more deeply about whether the system works - and working to improve it.

And finally, last month a longtime friend had a completely unsatisfactory experience - at BIDMC, as it happens - and found the information she needed by consulting a patient community online, at my recommendation.

So I am just so, so clear that this whole system is populated by mortals, damn flawed mortals. People who worked their buns off to get here and continue to work their buns off, even as cost and time pressures increase relentlessly. And somehow they manage to SMILE and BE WITH ME.

The question is, what can we do that will make a difference, that will keep improving the system?

Assign blame? You know, when I posted about the Minnesota error, a local authority commented "culpability rests solely in the hands of the surgeon." What good does that do? Can't we create more good by asking, thoroughly, "What can we do better?"

He went on to detail all the processes they have in place - which didn't work. We need to understand why. It takes guts and heart for all involved to bare their souls honestly, for a better future.

@nonlocal, you suggest that those present might view participation in the video as punishment. I can see that. But I can also see this: think of what an incredible difference it would make in the future, every time there's an error of any size, if people vividly have in mind the knowledge that people who make mistakes and are honest about them are not excoriated - that humans are respected, even as they're expected to do everything in their power to do it 100% perfect. What a tremendous contribution that would be to the new world of healthcare we all want.

Anonymous said...


Even though I've done this personally, I'm also going to commend you publicly. You and your team's rapid honest disclosure of this adverse medical event will
hopefully be a trend setter. Not only did you share it with your patient and staff immediately, you shared it with the world. Honesty and learning from a mistake are all that most survivors crave. You spotlighted the "blackboard" for
your global audience and used a tragedy as a teaching moment. Your team obviously leads with integrity and humanity and I thank you for the courage of your organization, including your physicians and attorneys.

The patients and families who have experienced lack of disclosure following a horrific adverse medical event (as we have) have "screamed" as loudly as we can for others that this antiquated accepted behavior of secrecy is cruel and inhumane. Our family has been waiting for over 7 years for answers regarding our child's death. Pleas for honesty have fallen on deaf ears. Your patient has been saved from this
added pain. Someone is finally listening!
Your friend

Anonymous said...

"The mistakes occurred after the patient was sedated."


But I guess my point still would be: Are patients invited and encouraged to be part of the process? Is there some value in teaching patients to expect there will be a time-out before their surgery - and that if this doesn't take place, the patient and/or family should speak up and remind the team to take a time-out?

I just think there's gotta be some patient involvement here. I realize there's a limit to what can be demanded of patients, and at the end of the day it's still the medical team's responsibility. But we can't expect you to do this alone.

Anonymous said...

I think it's actually really important to know some of the details of the case in order to asses the gravity of what happened. Medical mistakes happen all the time. Just today, one of my patients got a chest xray done before his dialysis instead of after. Not a huge deal. Not like operating on the wrong body part, right? Operating on the wrong body part sounds awful - and sometimes it is, but I think we need some context. A diabetic in for a foot amputation, for example probably has 2 really diseased feet. But maybe one's a little worse than the other. If you amputate the wrong one, let's face, the other one was probably going to go soon anyway. Taking out a healthy kidney, though and leaving the one with the tumor - that's another story.

Anonymous said...

Dear Mr. Levy,

I have an idea. Perhaps the surgeon (as opposed to a PA, NP, intern, or Family Doc) should perform and record the complete preop history and physical exam requisite for surgery. This ancient protocol ensures that the surgeon knows the patient for the sake of both...;but it is not followed any more.

Don't waste your time with high tech digital video that can be played from your state of the art computers...just be sure the suirgeon examines the patient before he/she is in the OR...the old fashioned way.

Noah Zark

Anonymous said...

Hello. Somebody makes mention of "giving the green light" above...and maybe this was suggested already. But what about a traffic light stationed under the clock on the wall in the OR...It stays red until the "all clear" is given and then goes green. At that point an incision can be made. Just another safety measure. Like many things in life and in health care I suppose...this failure will end up helping a lot of us.

Bluebirdy said...

This same thing happened to me, and it was handled horribly. I am so happy to see that they are not all handled this way. The Dr. removed the wrong ovary, so I continued to have pain from the bad ovary, and the nurses were not told, so they could not tell me why I was cut in the wrong place and still in pain. The Dr. kept giving me pain shots for 6 weeks and never told me why I kept hurting. Then I went to the E.R. and they discovered the wrong ovary was gone and they suggested I got to another town to get the correct one removed so it wouldn't cause a scandal in that town. Being only 24, I did, not knowing better. That stopped my child bearing years. I went to a lawyer who also turned out to be a crooked lawyer, so I never did get compensation for losing my ability to have children. I had to pay for both surgeries out of my own pocket. I would have appreciated someone helping me with those bills since the mistake was made. Thanks for giving me a bit of hope that doctors don't always cover up each other's mistakes.

e-Patient Dave said...

Bluebirdy, your story makes me feel physically ill. It reminds me that stories like this were not rare a generation ago, and I desperately hope they are rare today.

I'd like to learn more about your story, in the hope that it can help others. I couldn't find contact info on your blogs. If you want, write epatientdave at comcast dot net.

e-Patient Dave said...

Returning to this thread, I just read one of the other linked blog posts. You (all of you) MUST read this, from a New York personal injury attorney. It's powerful, and it makes me think that it may be time to sell hockey sticks in Hades.

A Tale of Two Hospitals: One Covers-Up and One Apologizes

I mean, really: read it, the whole thing. It's not long.

Anonymous said...

Paul and BIDMC staff,
Thanks for serving as role models for how to handle these types of tragedies. Transparency is step one, and your openness and mutual support will reach many on the health care community nationally as the new standard for managing harmful circumstances. You are also working every day to create a culture of safety, one where each staff member feels empowered to "stop the line" should they see a risky circumstance. The incident shows that you are not there yet (no one in helath care is) but the other blogs from the SPIRIT program shows how much progress you are making.
Can you let us know from time to time how the patient is doing?
It would be helpful also for you to show how you are supporting the "second victims" in this case....the physician and the nursing staff in the operating room. As you know, we lose so many great professionals each year because we fail as leaders to make processes as error-proof as they can be, and because we don't provide some support to them after an incident....just another request for you to serve as the leaders in improving care for the rest for the country! Thanks for all.

Anonymous said...

Thank you, Maureen. We did and continue to offer and provide counseling services to the staff involved. As you would understand, they were all very distressed by what happened. They are kind and dedicated people, and they were in shock that they could have participated in this kind of error. We intend to stand by them.

I do not feel it is right for me to comment on the status of the patient. A number of us have talked to the patient, but I do not think it is my place to offer a public assessment of his/her condition or feelings. As we have said before, the physical effect of the wrong-side surgery should not be lasting, but to say more beyond that is not for me to do.

I welcome your comments and others from IHI on the post I made today on lessons learned by Tom Botts from Shell. I think they will resonate with many of the points your experts have made.

Unknown said...

I continue to be impressed with BIDMC and the leadership of Paul Levy. I'm a healthcare information systems programmer with an academic background in biology and psychology and while reading through John Halamka's and your posts about this error, I had a practical thought.

I'm sure we've all had the experience of missing a typo when proofreading something because we've looked at it so many times that we see *what we expect* to see, not what is really on the paper. I expect the same phenomenon can happen during a text-based Time Out. What about also having a sound component, either the patient recording her/his identifying info, procedure and side or using a text-to-speech program? When the whole OR hears it, something that's wrong may jump out at them. When what the OR staff hears is one person reading from text, the proofreading phenomenon can come into play.

Thank you for educating the public to expect a 'culture of safety' in one of our most precious resources, our healthcare system.

Anonymous said...

My name is Josephine and I am a member of Please visit our website. Please add your name and comment to the "Improvement in Quality of Patient Care Petition" We are not looking for donations but for citizens who care like us who want to volunteer their time to help expose the truth about our healthcare system. Please join us to expose the truth. Many thanks in advance for your support.

Kindest regards,
Josephine Cicchini

Anonymous said...

So much for transparency & view of this boston herald story, sounds more like Levy is better at spin and cya.

Posted by a former BI patient

Jennifer said...

Thank you for your timely, bold apology and honest discussion!
Jennifer Thomas, Ph.D.

Anonymous said...

Funny how this hospital can outwardly take responsibility for a wrong side surgery and the hospital where my daughter had the wrong ovary removed takes no responsibility. They did the day of surgery, they did the day we sat down with the risk manager and she said they wanted to settle with my daughter but when this got presented to the hospital attorney they are not responsible now. Is it all lip service?
This has been such a nightmare for my daughter and all of our family and we are so secluded and alone. My daughter even reminded her doctor to take her lefy ovary out right before surgery and she said don't worry. Ha... so much for patient involvement. Bitterness and mistrust becomes a way of life after something like this occurs, the announcement by this hospital administrator seems to be a way of lightning the seriousness of this. You have a job to do when you operate on someone, they have entrusted their life in your hands and the hands of everyone in that operating room. You do not take your eye off the ball, if you can't handle that then get out of the game!!

e-Patient Dave said...

To the anonymous commenter last night, whoever you are -

Your pain is so apparent, and for obvious reasons. I can barely imagine your loss, compounded by an apparently heartless organization that doesn't even know the abundant evidence that "I'm sorry" benefits everyone.

There's good reason why this blog post has an incredible list of 29 articles that have referred people here. This is a BIG issue.

I'm just a patient at BIDMC, but I want to offer something that a lot of people have found useful. It won't and can't undo what's done, but it can help get through the days. And the people involved at that hospital might, too. It's Medically Induced Trauma Support Services, and it was formed by a patient who was harmed and the physician who harmed her. They do remarkable work. When / if the time is right for you, have a look at their site.

My heart goes out to you -


Anonymous said...

Refusal to listen to the patient is intolerable.
Suggestions for recording pre-operative and operative procedures have merit. Electronic control of "unlocking" the first operative procedure should be based upon confirmed attention to the preoperative disciplines. Several individuals could verify the pre-op procedures were properly executed, by means of passwords entered to unlock the instrumentation for the operative phase, and reflect responsibility for the accuracy of entries. There were general references to controls, as just mentioned. Details count!

Daniel Alvarez Arribas said...

"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."

So what exactly did you think before that incidence? Aren't those learnings among the most trivial things on earth? Isn't it just OBVIOUS that distracted people tend to be more prone to committing mistakes? Why do things have to go wrong before people realize that they have to stick to their protocol EVERY TIME? This sounds like you just learned something even the most basic common sense should have told you.
Disclosure and quick and proper response to mistakes all nice and well, but I wonder why "never events" still happen in the first place, due to pathetic "reasons" like these. I mean those people were professional surgeons, right? Skipping their universal protocol just out of mere carelessness... because that is what it comes down to at the end of all talking. Instead of using this incidence as an opportunity to blow smoke up your teams ass for your QA work, you should take some blame for WHAT actually happened. Because according to the description, it was simply CARELESSNESS. Every system gastronomy restaurant could have told you that consistency is key. And, yes, consistency means doing it 100% of the times, under all circumstances, not just 99% of the times whenever it does not matter anyway. No need to have a wrong-site surgery incident to learn that...

At least you are being honest.

Paul Levy said...

The rate of wrong site surgeries in the US has stayed pretty constant, so it is clear that these matters are still not understood or practiced in a lot of the country.

We learned a lot from this incident about how to more properly design the protocol and train people. That learning took place across the hospital because we publicized this event. Most places still are not willing to publicly discuss such errors when they occur, even with their staff.

Unknown said...

Awesome ! #HA405USI