Surgeon operates on patient's wrong side

A national specialist in the field of patient safety said that hospitals are increasingly owning up to their mistakes but described the decision by Beth Israel Deaconess to send an e-mail to hundreds of staff members as an unusual act of openness.

When a medical mistake happens, "it's everybody's worst nightmare," said Jim Conway, a senior vice president at the Institute for Healthcare Improvement, a Cambridge think tank that works with hospitals to improve safety and efficiency. "So what you want to do is disclose it to the [hospital] community, so the community can figure out how they can advance their practice and advance their role so this never happens again."

In an interview, Dr. Kenneth Sands, senior vice president of health care quality at Beth Israel Deaconess, said it had been "at least several years" since such an error had been made at the hospital, which is affiliated with Harvard Medical School.

The memo from Sands and hospital chief executive officer Paul Levy describes the surgery as "a horrifying story."

According to that document and an interview with Sands, the patient underwent surgery on what was described as a hectic day. The memo depicts the surgeon as being "distracted by thoughts of how best to approach the case" in the minute preceding the operation.

"There was still some last minute 'i's' getting dotting and 't's' getting crossed that maybe had people a little bit out of their routine," Sands said.

While declining to go into detail about the surgical procedure, Sands said that "there are procedures that happen every day and then there are procedures that are somewhat less common, and this was in that latter category."

The hospital did not disclose the identity of the patient or surgeon, saying that if too many details about the operation were disclosed, the patient's confidentiality could be compromised.

Sands said that medical workers used a marker to correctly label the side of the patient that should have been operated on but that, somehow, the surgeon failed to notice the marking.

"I think he began prepping without looking for the mark and, for whatever reason, he believed he was on the correct side," Sands said.

Perhaps most crucially, the team of medical workers hovering in the operating room neglected to conduct what's known as a "time out" before the surgeon first placed his scalpel on the patient. Time outs are safety procedures that require the operating team to verbally call out, "Right patient, right procedure, right location."

The error was discovered when the patient was recovering from the surgery. Later that afternoon, the patient was told about the mistake.

"We waited until the patient was awake enough to get the news, and at that point, the surgeon talked to the patient and gave a full explanation and a full apology," Sands said.

The patient has left the hospital and has made no decision about whether to have the correct operation -- and if, so, at what hospital.