Thursday, December 10, 2009

Not an early adopter

#IHI09 Following a wrong side surgery a year-and-a-half ago, an interdisciplinary team of our staff revamped our pre-surgical protocol and developed training materials for all OR staff. Here is a sequence of excerpts of recent emails on the topic.

Please rest assured that this doctor is in a distinct minority, at least in our hospital. Unfortunately, I heard reports at the IHI National Forum from people in other hospitals that his view remains all too common elsewhere.

Surgeons and residents,
Dr. Hurst (Acting Chair of Surgery) and I wanted to let you know you must complete this training module. All OR users must do this. . . .

Please click on the link below to go through the module and do the few questions required. Your completion will be recorded in performance manager, but if necessary send your verification e-mail to your supervisor so they can make sure you have been credited with completion. It is required of all attendings and residents using the operating rooms.

This is an important issue for the institution, as it was one of the corrective actions created when we had the wrong site surgery a while back. . . .

I am sending this out today, as there is a proposal being forwarded to the OR Executive Committee to block OR scheduling and resident access to the ORs until the module is completed. In so doing it is hoped we will have significant compliance. . . .

Thanks in advance for your help with this. If at all possible do it today.
Don Moorman, Vice Chair

Reply from one surgeon, sent (probably in error) to the entire mailing list!

I realize you are only the messenger, but in my humble opinion, this is the classic example of “the tail waging the dog”. Because some goofball operated on the wrong side, we now must all engage in this annoying practice every time we operate. It’s that kind of world, I guess. Too bad!

Response from Doug Hanto, Chief of the Transplantation Division, also sent to the entire mailing list:

I can guarantee you that every surgeon who has operated on the wrong side or left a lap or instrument in a patient never thought it could ever happen to them. These procedures are designed to protect patients from errors that even with the best intentions can happen to the best of us unless we are extra vigilant and have policies and procedures like this in place. . . .




Anonymous said...

To which I would reply with the following quote in an interview with one of the members of the original IOM committee on "To err is human" 10 years ago:

"Dr. Cassel: When we think about how we train doctors, which I spend a lot of time doing, they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change."
("The Hospitalist", 11/09)

Helloooo, my colleagues; time to wake up now.

nonlocal MD

Anonymous said...


I recently had hand surgery at another hospital in the Boston area. Prior to going into the OR, every member of the surgical team talked to me, asking the same questions, including which hand, right or left. It was quite reassuring to know that everyone was on the same page. I had no worries that they were somehow cut open the wrong hand.

Anonymous said...

Transferred from Facebook:

Rick: That is a great response from Dr. Hanto.

Debora: He needs to talk to Duke about the transplant error - the bigger they are the harder they fall.

Michael said...

How I'd respond:

Many of us who excel in our work are inclined to believe that we'll never make a mistake. Perhaps you personally will never make a mistake. You can still reduce the chance of mistakes made by your colleagues by implementing, improving, and honoring these policies.

Anonymous said...

I was recently in an Emergency Room due to a fall with a severely dislocated shoulder. Part of the treatment involved setting up an IV with pain killers and muscle relaxants.

I must have been asked 10 times if I had any known allergies to medications. In the past, I might have been annoyed at the redundancy of the questions.

Since I have been following this blog for some time, I saw the whole experience in a completely different light. I now saw a team that was checking and double-checking to make sure there were no mistakes.

So I answered patiently (bad pun) each time I was asked, appreciating the fact that the ER was being that careful.