Tuesday, September 23, 2008

Follow-up to "never" event

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

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

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

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

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

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

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

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

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

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

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

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


Anonymous said...

Dear Elaine,

I have not posted your comment because I generally do not post complaints of the sort you have mentioned on this blog. I am happy to investigate the matters you raised, but I need to have the specifics -- your full name, dates, and so on -- so we can do a full analysis and get back to you. I can't do that here because it would disclose lots of personal information about you.

Anonymous said...

i think its great that you openly comment on the wrong surgery issue.. however I noticed you fell into the solution that most hospitals always do.. Making it the job of someone else to make sure the physcian does what he/she is supposed to.. These people are brilliant and you cant rely on them to be responsible to do a time out? they are the commanders of the ship arent they? Hospitals are so afraid and protective of their prima doctors that they make all the other secretaries nurses techs pharmacists et al responsible for making sure they do their job!
Of course then it is easier to fire the peopel when these kind of things happen..who misses a tech or a nurse right? I am sure you are well intentioned but the solution should be the doctor or some kind of technology reminder..not another lower person..

Anonymous said...

No, no, no, you misunderstand. This is no attempt to transfer blame to other people if there is a failure to have a time out. That would be totally wrong. But, it is important to remember that, sometimes, MDs forget to do what they are supposed to. For the sake of the patient, you want everybody else in the room to feel empowered and encouraged to stop a bigger mistake from happening. The other people in the room are not "lower people" in any sense of the word. They are all part of a care delivery team. Everyone on that team has a responsibility to call out problems that might hurt a patient. We make clear that the doctor is the captain of the ship, but we also take care to remember that the captain sometimes makes errors, too, and we try to have a system in place that accounts for that contingency.

Anonymous said...

You know, just speaking as the devil's advocate, it strikes me as ironic that the doctor is allowed to "forget" to initiate the timeout, but it is now hospital policy that the scrub person will not arm/mount the scalpel until the timeout has occurred, as a failsafe. What if the scrub person "forgets" this policy, and arms the scalpel without ensuring the timeout has been performed? They can be fired for not following policy. But the doctor gets away scot free because he made a "mistake".
You understand I am saying this as a doctor who has made my own errors, so I know very well what your intentions were with this corrective action and policy change. But it doesn't change the fact that we docs are treated differently than hospital personnel - and we know it(and so do they). Therein perhaps lies the root of the problem that we are often the last to conform with policies such as handwashing.
(And yes, I know my colleagues will say that the threat of malpractice is our equivalent of a termination threat; I've said that myself before.)
Just an observation.

nonlocal MD

Anonymous said...

Dear nonlocal,

You say: 'They can be fired for not following policy. But the doctor gets away scot free because he made a "mistake".'

I don't know what I can say beyond what I already have that we are not seeking ways to punish people. We have a very strong "no blame" policy in the hope of getting people to report their own mistakes so we can all learn from them and improve. That would apply to surg techs, nurses, doctors, and everyone else.

What we seek in this policy and elsewhere is to create an environment in which all people feel a responsibility for patient safety and, where we think it might be effective, to try to build in "hard stops" to help overcome the fact that people sometimes do make errors.

If we imagine the scenario you posit, the doctor, too, would still have erred. As would everyone else standing around the table. That would represent a systemic failure, as well as personal mistakes on the part of everyone there, and would provide us with yet another (unfortunate) opportunity to revisit our overall approaching to avoiding that kind of error.

Please read the commentary below on this whole punishment issue. http://runningahospital.blogspot.com/2008/07/guide-to-just-decisions-about-behavior.html

Anonymous said...


I thoroughly get your point; perhaps you misunderstood mine. I was really saying that we docs get let off the hook frequently when we shouldn't. (Although I know you wouldn't fire someone for not following policy, the implicit threat is still in their heads - but not for docs.) There needs to be more accountability within the profession. I am still struggling with this whole idea of the "gray area" in your cited link as applied to physicians.


Anonymous said...

I recently attended a conference specifically for CEOs and healthcare leaders. The bottom line for the discussion was that physicians are the ones that make the money for the organization. We were told to focus our attention on physician recruitment. There was no discussion about hiring talented nurses or other staff. The patient was not the focus but the physician was. I think this relates to your discussion here. Putting everyone on even ground is my goal but how do we accomplish that in this environment?

Anonymous said...

Sounds like wrong-headed presentations at your conference.

Anonymous said...

I'd like to take a shot at anon 7:48's question, since this situation is not uncommon in community hospitals, but probably rare in academic centers, especially Boston!
I know community hospital administrators dream of certain service lines putting them on easy street,such as bariatric surgery, etc. Some of these scenarios are more realistic than others.
Also, it's very common for high-producing docs in community hospitals to threaten to take their patients across town to the competitor if their hospital 'gives them a hard time' (e.g. tries to enforce any standard of behavior on them). This, of course, amounts to blackmail and the only thing I can say is that you have to recruit the right type of people in the first place (beware if they talk too much about $$ and less about the patients during their interviews!) and let them know up front (before they come, that is) that system quality and patient safety are high on your list of priorities, and everyone in the hospital is expected to comply.
It also helps to consistently and firmly advocate this stance in your medical executive committee and board meetings so that it becomes part of your culture, before Dr. Big ever shows up. A strong medical executive committee can work wonders.
Last, recent Joint Commission standards, such as those concerning disruptive physicians and assuring patient safety, are a big help in enforcing the rules since you can simply tell Dr. Big any hospital at which he/she practices will lose their accreditation if certain practices are not adhered to.
I decry that medicine has come to this, but such is modern reality as physicians follow Wall Street down the entrepreneurial road. Hopefully, down the line as the shape of healthcare reform becomes clearer, including perhaps the shotgun marriage of physician practices and hospitals by bundled reimbursement, closer cooperation between these two entities will improve patient care.

nonlocal MD