Surgeon operates on patient's wrong side

great what I need to hear

Dear Boston.com parasite editors,

Doctors are human too, you know? Are they not prone to mistakes? Is it not the risk we take when humans treat humans? Stop crucifying these people and let the issue remain private.

Clearly, marking the *correct* side alone is not enough.

People responsible for prepping the patient should mark "NOT THIS SIDE" on the *wrong* side, as well as "THIS SIDE" on the *correct* side.

Sheesh...

Surgeons earning millions of dollars per year, who perform enormous numbers of surgeries, who keep clinical patients waiting for hours and appear at their convenience with the simple explanation for their tardiness, "I was in surgery", as if this represents a legitimate excuse to keep a dozen or more people waiting...often fall prey to morbid levels of narcissism which can be dangerous to those whose lives they have in their hands.

In this age of rampant deregulation, we must revisit the rationale behind rational regulation of human activity, whether it be that of a surgeon or of corporate executives who's decisions can seriously impact others. The key operative term here is "human", you know, the one's who make mistakes when moral hazards allow, mistakes which hurt others.

As an anesthesiologist, I have been disappointed numerous times when a time-out is initiated by a member of the OR team and the surgeon refuses to respond. Unfortunately, some surgeons still view themselves as infallible and not prone to error. Until we rid ourselves of this hierarchial mindset in what should undoubedly be a high-reliability organization, these unforuntate and inexcusable errors will contiue to occur.

Fortunately for the patient, the surgery did not require removal of vital organs. I would surmise that this surgeon owes more than a mere apology to the patient. He/she owes an explanation to the hospital and the medical ethics board.

This is not a small mistake. The surgeon could have caused serious harm to the patient.

As a board certified physician, I do not appreciate Mr. Devito's comments, as I believe they stem from ignorance. This physician works for the Beth Israel system - I am quite sure he is not making "millions of dollars" - academic physicians make much less money on average than a physician in private practice Not only is his time being spent operating on patients, but also supervising residents as well as medical students, most likely. "I was in surgery" isn't used as an excuse - cases sometimes run over-time so that the t's can be crossed and the i's can be dotted. And for that reason, surgeons are sometimes late for clinic. The error is inexcusable, yes, but it was not made because the surgeon is a narcissist. You can bet your ass that this doctor knows it's his fault and feels awful.

It will eventually come out but the wrong leg was removed. In the email sent out to staff it states that the "that the patient is home recovering" like it was a routine mistake. He is recovering all right and now it is also known why health care costs are so high.

Elderly Wheeze:

'What's the difference between a practicing surgeon and Almighty God?'

'Almighty God does not believe he is a practicing surgeon.'

Ba-Da-BOOM.

Mistakes are going to happen. We all just hope it doesnt happen to us.
This is unbelievable but believable.
Whenever humans are involved, there will be mistakes. UGh!

Mr Devito is completely wrong. Physicians are NOT making millions.

When a physician bills $100's for a service, he/she may only get reimbursed $20
from the insurance company.
When a plumber comes to your house, he/she bills you $100 (probably more) and gets 100% of what he/she charges. So, what field would you rather go into?

Massachusettes is in trouble. The smart would be young physicians are NOT going into medicine today because its simply a pain in the neck to practice medicine today thanks to the insurance companies who are getting rich at the expense of the physicians. The future physician is not going to be the cream of the crop. There will be many more mistakes.

Well, that was a slight tangent huh?

Dear Mr. DeVito-

Your characterization of physicians and surgeons is, cynical, sad, and inaccurate. If that surgeon works for an academic center, his annual income is undoubtedly less than the cost of his/her medical education, which in turn rivals the median cost of a home in Massachusetts. There are certainly easier ways to earn a living.

As far as narcissism goes, "I was in surgery " is an excellent reason to be late for clinic-just ask the patient under the knife whether they would prefer the surgeon take their time to do the job right, or promptly arrive to clinic.

The patient in this case suffered an egregious complication as a result of a communication error. The patient's life will suffer as a consequence and a good surgeon's career is likely finished. There is plenty here to discuss and to think about, but your histrionic comments are unhelpful.

I donated a kidney to my sister 4 yrs. ago and a surgeon at BI did the surgery and they had an unrelated member of the hospital come in to ask me what kidney I was donating, on which side, etc. and he was the one to mark the incision spots.
I also saw the surgeon while in the OR right before they put me under and he repeated which kidney he was going to take, etc. I thought the whole process was very thorough. Since this was a planned operation and not an emergency, maybe they have more time to do this type of double checking.
Things like this happen, I guess and they are only human. I find it interesting that when doctors save people's lives they are praised like they are God, but when they make mistakes, they are accused of having "God complexes". We can't have it both ways. The fact is, surgeons need to be different and quite frankly I don't think it is really necessary that they even have a good bedside manner. Let the nurses take care of that end. A surgeon has to be able to rise above all "normal" human emotions to get the job done. If one saves my life but is a complete a** to deal with, so be it. I don't have to live with him/her.

To all the docs who have responded... how about your names? I have friends who are docs as well as relatives. I hear amazing stories they tell. Lets face it... no one is perfect, but I can understand where Mr. Devito is coming from. Some times the lack of disrespect by surgeons is amazing. Very arogant. When my friend was a resident she came home with her hands all red from the surgeon who thought it funny to beat up on a resident. I have personally had mistakes made on me and NO apolgy. Almost cost me my kidneys. Great job! Read the posts on Medscape and you'll see. I have had docs that were great... but those surgeons...UGH! Just 3 of the bunch had any class. (typing fast so please excuse the typos) Be well all:o)

AS a study has shown... there wouldn't be so many law suit

I find the god comments interesting. It must feel like god to cut open bodies and save people's lives.. but a life of good deeds and great surgeries can be undone in a moment when safety practices are ignored..and surgeons must be held accountable when they skip safety mechanisms.. end of story...

how would you like to be the guy with no leg? just because someone didnt do an easy easy easy safety check?

and to Lisa..I am glad you had a great surgery but no human being surgeon or not has the right to act rude especially to someone with a health problem.. it is a sad society that feels obligated to tolerate unprofessional behavior in talented individuals.. look at what manny ramirez gets away with

Mr Devito,
Get a life and give this poor surgeon a break,I am sure he already feels terrible.Surgeons are human too and can make errors.If you think they are making millions of dollars,you are welcome to join the club.

mr. devito is dead wrong. it sounds like he was kept waiting in clinic by some surgeon and is now soured on the whole medical profession. i am sure mr. devito is a very important person and has very important engagements that must have been disrupted. however, i think that the next time mr. devito goes to the OR, he would rather the surgeon to stay and perform the procedure properly, rather than rush to stick exactly to his clinic appointments.

Sadly, I had surgery on my breast (cancer surgery) at Beth Isreal and jokingly I put a peice of white tape on my left breast that said "not this one" - I now am glad I did so!!! They thought it was funny,but, heck, it helped !!!

>> " whether to have the correct operation -- and if, so, at what hospital."

Er, my guess would be probably one in North Carolina.

"For whoever exalteth himself shall be abased, and he that humbleth himself shall be exalted." - Luke 14:11

It's true that physicians are NOT making millions of dollars, and that fewer bright people are going into the field because of the headaches involved. It's also true that physicians pay ridiculous premiums to malpractice insurance companies. But from experience I'll tell you it's not the insurance companies getting rich in these situations. Commerical insurance companies are struggling, consolidated and tanking - and have been for years. The huge premiums go to pay the defense lawyers that defend the doctors from the mind-boggling number of lawsuits filed against them. It doesn't matter that most of these are eventually dismissed or won by the doctors - we only hear about the unusual large verdict. Defending them, even the frivilous ones, are very expensive, and we end up in this vicious cycle. Who's getting rich? Mostly the lawyers...

Having had too many surgeries to mention, I find this article interesting. I have my surgeries done in Boston and at local suburban hospitals. At all times during surgeries, I am asked questions. Where are we operating? What is your name? Why are we operating? Do you have any questions? I sometimes wish they would leave me alone, I am nervous enough prior to surgery. HOWEVER, the end results have always been worth the questions. There have been no mistakes. I do not agree with the statement made by another 'poster.' I believe the doctors bed side manner shows his/her connection to me and my proceedure, and a doctor who cares about me will not make mistakes. I also question whether it is always a good idea to go into a major teaching hospital in Boston or stay local. I make this decision depending on the particular surgery I am having and where the "experts" are located. Sometimes it is the local hospitals that take the extra time required to "do it right the first time." If you are familiar with catarac surgery, I can not tell you the "countless" times I was asked which eye was being operated on. I was asked by the operating doctor himself, just prior to surgery. Even though the eye was CLEARLY marked, I'm sure he wanted to be certain the marking was correct. This is the mark of an excellent doctor, not a doctor who will have to apologize to his patient later!!!

Please allow me to add my comments, as a wife of a surgeon -- My husband does NOT make millions (Lord knows I wish he did); we don't drive luxury cars, live in a McMansion, or belong to a country club, those days are gone. My husband does not have a God complex, he makes house calls for patients who cannot afford the transportation to come to see him, he waives fees for impoverished people, he genuinely cares about quality of health care, perseverates over any perceived "inadequacies" in his health care delivery, has stayed up nights wondering if 12 stitches rather than 13 were enough. Is he a saint? an aberrancy? I think not. Having been a nurse and having known many surgeons --there are those with God complexes and there are those like my husband who has saved peoples lives only to be reamed out for an "ugly" scar --My husband can't tell you off the top of his head how many successful, uncomplicated operations he's performed in the last 20 years, but he can recite to detail every case that did not have the desired outcome. Why? because they take it home with them, they live with it, they wrestle it, they are human and have never set out to "do harm".

Medicine is a science of the human, it is an imperfect science delivered by a imperfect humans with God given skill and mind; accidents do happen and I have to agree with ER doc, this doctor who made the mistake is most likely shaken and spending a lot of time beating himself up.

BRAVO to the BID for being so publically transparent!

Nice, no comfort in that article. I will have the R hip said 1000X before my surgery.

Much of what a doctor makes goes towards paying their medical malpractice insurance which i hear is so high in some places that doctors have been forced to move to a different state.
The article stated clearly that the mistake was not a life threatening mistake so all i can say is ...time heals all wounds.

A few comments from a young(er) specialist in Boston:

1. The incident reported here is undoubtedly a terrible mistake. I feel deeply for the injured patient and the surgeon who tried to care for him.
2. There is NO surgeon or specialist in this town making millions of dollars from taking care of patients.
3. No good surgeon ever went into this field to make money. There was a period of time in the US (say, from 1950 to the mid eighties) when doctors got away with unregulated fee for service. No more. And rightly so.
4. I bristle when I hear people lament the dearth of "good" people going into medicine. There are plenty of excellent young students going into medicine. They are still "cream of the crop," and they are motivated by much more than money or prestige. It takes more intellect and skill than ever before to be a good doctor. Despite what they think, most established doctors wouldn't get through if they tried again-in fact, many only had to take their board exams once-a long time ago (just ask Bill Frist about HIV if you want a sense of what I am talking about). Conversely, any C student with a firm handshake and a good smile can sell junk bonds and retire early.
5. One does NOT feel like God when operating on patients. It is an awsome and humbling experience. Not everyone can do it. In fact, most people cannot. Frankly, we're amazed that one can get away with it-fortunately, we have a couple thousand years of other people's mistakes to learn from (Check out descriptions of Galen's early work and decide whether you would want him as your surgeon).
6. Insurance companies ARE making huge profits-they are among the most profitable investment groups out there, as a sector. Holly J is woefully confused as she conflates liability premiums with health care policies; they are completely unrelated. Over 30% of patient's health care premiums go directly to overhead (executive salaries). No self respecting health insurance company would be involved in malpractice insurance-that would be throwing good money after bad. Most local malpractice groups are self-insured captive groups with funds invested offshore-they charge whatever they want, and the premiums are in no way related to the cost of health care services. They are related to the calculated risk of liability for any given specialty, balanced against whatever the market will bear.
7. Holly J is right about tort reform-it is desperately needed in this country.

Again, I feel for the patient injured in the above case, and my heart goes out to the family as well. I simply could not stand down and let this incident become a platform for people to spread disinformation, however heartfelt it is.

A few comments from a young(er) specialist in Boston:

1. The incident reported here is undoubtedly a terrible mistake. I feel deeply for the injured patient and the surgeon who tried to care for him.
2. There is NO surgeon or specialist in this town making millions of dollars from taking care of patients.
3. No good surgeon ever went into this field to make money. There was a period of time in the US (say, from 1950 to the mid eighties) when doctors got away with unregulated fee for service. No more. And rightly so.
4. I bristle when I hear people lament the dearth of "good" people going into medicine. There are plenty of excellent young students going into medicine. They are still "cream of the crop," and they are motivated by much more than money or prestige. It takes more intellect and skill than ever before to be a good doctor. Despite what they think, most established doctors wouldn't get through if they tried again-in fact, many only had to take their board exams once-a long time ago (just ask Bill Frist about HIV if you want a sense of what I am talking about). Conversely, any C student with a firm handshake and a good smile can sell junk bonds and retire early.
5. One does NOT feel like God when operating on patients. It is an awsome and humbling experience. Not everyone can do it. In fact, most people cannot. Frankly, we're amazed that one can get away with it-fortunately, we have a couple thousand years of other people's mistakes to learn from (Check out descriptions of Galen's early work and decide whether you would want him as your surgeon).
6. Insurance companies ARE making huge profits-they are among the most profitable investment groups out there, as a sector. Holly J is woefully confused as she conflates liability premiums with health care policies; they are completely unrelated. Over 30% of patient's health care premiums go directly to overhead (executive salaries). No self respecting health insurance company would be involved in malpractice insurance-that would be throwing good money after bad. Most local malpractice groups are self-insured captive groups with funds invested offshore-they charge whatever they want, and the premiums are in no way related to the cost of health care services. They are related to the calculated risk of liability for any given specialty, balanced against whatever the market will bear.
7. Holly J is right about tort reform-it is desperately needed in this country.

Again, I feel for the patient injured in the above case, and my heart goes out to the family as well. I simply could not stand down and let this incident become a platform for people to spread disinformation, however heartfelt it is.

What it comes down to is the hospital had procedures in place that if followed this would not have happened. The only sympathy I have is for the patient.

The rticle reads "an experienced surgeon" was it truly or was it a "new grad" with supervision? The mistake was on a life and haste makes waste!!

I once had a transplant surgeon tell me about the extraordinary difficulty of his work. It seems there's no regularity in the way human bodies make parts so, for example, the heart from one adult male does not necessarily fit easily in the chest of another. This lack of standardization means we ought not expect assembly line regularity from surgeons doing any procedure.

As far as the lack of following proper procedures before operating, reminds me of operating a motor vehicle, how many of us have not pushed a traffic light, changed lanes w/o checking our blind spot or such? We naturally feel most dependent when it comes to surgery, but that family we might have involved in our driving would have become pretty dependent also and had we caused death or injury I doubt it would have gotten this kind of scrutiny.

How about those folks from our government? Started war operations, claimed to see Xs and mushroom clouds that were not there? Lots of lives, body parts, trust and national treasure lost there. Where's the sense of proportion in response of that to a surgical slip?

It boggles my mind to see how incensed many people get over the money some doctors are paid. I doubt the highest paid US surgeon makes anywhere near as much money as the average CEO of a Fortune 500 company or the financial geniuses who brought us the Sub-Prime Fiasco, the price of oil, NAFTA job hemorrhaging or the recession in process. I often wonder what genuine qualifications those bozos have but I do have a sensible idea of what it takes to become a surgeon.

Mistakes like these happen more than people think I should know my daughter lost her life to medical errors, Everyone should read Fatal care, survuved in the US health system by Dr. Kumar, II true stories of families pain and suffering and two of those stories are from Massachusetts

How did academic surgeons crying poor mouth (and seriously, please) become a canard to derail this indictment of at least one surgeon's gross incompetence?

If this surgery was as devastating as removing the wrong leg (as one poster insinuates) this surgeon's career should be over. If it was something somewhat less devastating, this person should not be anywhere near an academic institution, presumably where best practices should be exemplified and promoted among future surgeons. I just don't think there's any equivocating beyond that.

This happens more than anyone thinks, because it's almost never reported.

Hey 'Jen'! ""For whoever exalteth himself shall be abased, and he that humbleth himself shall be exalted." - Luke 14:11"

LOL religitards make me laugh. I don't know why you people devote your entire lives to some fairy tale about an invisible, all-knowing all powerful sky fairy who watches over everything EVERYONE does and then judges you when you die, so 'you can live everlasting life...AFTER you die'...what a laugh. What makes you think humanity is so special that we'd have some invisible god watching over us? That's how strong your fear of death is, you'll believe that nonsense.

It's

What the surgeon is paid is irrelevant. Holly, I can sure assure you that average surgeon's income (not millions) is greater than that of an insurance defense attorney.
The mistake is inexcusable.

Doctors and other caregivers ARE human, and that is exactly why we need our medical system to begin taking patient safety seriously. BIDMC is one of the rare hospitals that is transparent about its quality (and occasional lack thereof). Obviously, they and the rest of the system still have far to go.

Medical care is complicated. It is dangerous. Systems need to be in place to ensure our safety. Little things like Dr. Pronovost's 'innovative' checklist make a huge difference, protecting our lives and controlling the skyrocketing cost of healthcare.

Go to www.hcfama.org/quality to join the patient movement for better quality care.

Policy not followed.....patient error! This is a terrible mistake!

I have worked in the hospital setting for 20 plus years, we all know how busy it is, staffing issues, etc etc etc. Well this is why the time out policy & many other saftey policies are is in place. To prevent us from making these kind of errors during extremely busy times.

The physican is not the only one that made the mistake.....many checks and balances broke down here along the way until the "time out"!

My sympathy to the patient, the physican, and all the staff involved. I am sure physician & all the staff involved are devistated.

We do so many positive things in health care, we need to continue to take care of each other, by supporting each other to reinforce saftey policies, so patients & staff never have to face this type of situation.

Hey Victoria, "bravo to BI for being so transparent????" Are you kidding me? You want to give them a standing ovation after making such a horrific medical mistake? I think not. Their narcissist CEO Paul Levy boasts and boasts about how safety and quality is his top priority. Maybe he should spend more time making sure his docs don't screw up, rather than worry about his daily postings on the blog. Anyway- he wasn't fully transparent on this one... The Globe found out about the error because administration sent out an internal memo that was probably leaked by one of their own employees! I'd call that selective transparency.

I don't care what anyone says, if you want excellent surgeons and the best in patient care- go West of Boston.

I applaud BIDMC's stand to make everything in the medical center transparent. I think that it is a strong and bold commitment for any organization to make to its patients and to the general public. When things are publicized it is a reminder for all healthcare workers that yes indeed mistakes happen and be even more cautious...if it can happen there, it can happen anywhere, so we must learn from all experiences -firsthand or from each publicized event.

I am just sick about how everyone must feel -patient most importantly who put his trust in the team, the surgeon, and every member of the staff involved in this patient's procedure. My heart goes out to both this patient -and to the team involved.

Good people do make mistakes, part of the human condition. We must always focus, as BIDMC does by being transparent, on how we can put better and better safeguards in place to prevent errors. Healthcare is a partnership. Those who go into healthcare are well educated, caring, and daring individuals who are trying to do a good job at helping others in need.

I have had more than 6 knee surgeries on the "right" knee, 3 on the "left" knee and a ruptured appendix that put me down for 8 weeks. The surgeons that have worked on me are more than caring and compitent. I had one post op infection but Dr. Doctor (yes, his REAL name) explained the how's and why's of the infection.
There may be unqualified doctores but they are human and "mistakes" will happen. neil

What might help with this type of wrong-sided surgery, is to have a family member or good friend accompany the patient to the surgery area and speak to the surgeon directly about the exact surgery site on the patient's body. The family member, acting as advocate, can request that the surgeon write on the patient's body the exact site where the incision will be made. If the surgeon is not available, then speak to the anesthesiologist and other medical staff who are present.
In my book, Critical Conditions: The Essential Hospital Guide To Get Your Loved One Out Alive, many steps are explained to help prevent these types of errors. Someone, a family or good friend, must get involved in a patient's hospital care. Even surgeons are human. www.criticalconditions.com

I congratulate the CEO for his complete disclosure to the hospital staff and the world. Having been in healthcare quality and regulatory for a long time, there is no excuse for not doing the Time Out. Healthcare speaks about Just Cultures and not firing anyone for making a mistake - but this is an out rage that an OR today can do a non-emergent procedure without the Time Out. Maybe the staff and physicians involved should have to make house calls to the patient to see how he/she is doing. Re-education isn't enough for this blatent violation of policy.

I believe everyone should be empathetic to this situation as it can, and does, happen every day somewhere by well-intentioned caregivers. One thing that I find as an expert in Root Cause Analysis (RCA) is our rush to judgment despite having no or littel facts to back up our assertions.

Even in this article the author uses words in quotes such as:

"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 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."

Using these wrods of doubt tells me these are assumptions at this point without validation. This puts an image in people's minds that this IS what happened and they leave the article believing this to be the true case. Certainly at this point these comments are hypotheses, but they are not facts.

People need to understand the full process that triggers such failures to occur. Human decision making, decisions to do or not to do something (Human Root Causes), trigger a series of physical consequences (Physical Root Causes) to occur that are observable. In this case the surgeon took certain actions and the outcomes of those actions were observable. This is a fact (the outcome of the action).

If we stop at this point and just blame people for making a bad decision, that is often referred to as "Witch Hunting" and is counterproductive to the investigative process.

What we should be doing is seeking to better understand why a well-educated and experienced caregiver made the decision they did, at the time they did! This is what is often overlooked in our rush to appease the public and powers that be with a response to the incident.

When we seek to understand human behavior we are looking for the Latent Root Causes which are associated with the organizational systems that influence decision making. These are organizational systems such as our policies, procedures, practices, purchasing habits, training routines, etc.

I think we can agree that the surgeon in this case did not intend for the outcome that resulted. So why did he think he was taking the right action at the time he took the action? Was he overloaded with cases? Was the patient record incorrect? Was he on a double shift and fatigued after working so many consecutive hours? Was the OR off schedule and there was rush to get back on schedule? Was this patient his original case or was the patient handed off to him? I do not know the details but there are many unanswered questions.

That is what needs to be drilled deeper and further understood. Only when we understand the rationale for a decision will we be able to prevent recurrence of the same behavior by that person and others in the future.

In our desire for immediate answers after such undesirable outcomes we feel the need to satisfy an appetite with something, even if it is not proven to be true or not the full story.

I applaud the CEO in this case for making the instant decision NOT to cover up the error and to instead try to learn from it so as to avoid a recurrence. Had he not taken this step we would have not know about it and chances are that there would be a rush to put the outcome to bed quickly, but not a rush to find the true Latent Causes.

Robert J. Latino
CEO
Reliability Center, Inc.
www.reliability.com

However, these decision

This surgeon, and all surgeons, could protect themselves and their patients from such a tragic error if they themselves perform and record what is called the complete preoperative history and physical, instead of having someone else do this for them. They just might know their patient a little better.

Dr. Who recalls how repetition was simultaneously used for retribution and behavior modification.

I shall pay attention; I shall pay attention: I shall pay attention; I shall pay attention; I shall pay attention; I shall pay attention: I shall pay attention; I shall pay attention; shall pay attention; I shall pay attention: I shall pay attention; I shall pay attention; I shall pay attention; I shall pay attention: I shall pay attention; I shall pay attention; 500 hundred more times before you can go to recess !

I am a surgeon. I never make 'mistakes' and always follow correct site procedures. I have occasional complications like everyone else but they are never due to my neglect or inexperience or 'loss of attention." I keep up on journals, meetings and continuing med education and I treat patients like I would want me or my family treated. I'm not a millionaire and never plan to be. Those who operate on the wrong side should lose their license permanently, and be brought up on charges of assault. Then maybe these 'mistakes' would disappear.

This incident represents a failure on the part of the entire surgical team. First, JCAHO requires that the surgeon marks the site, not someone else. Second, it is usually the circulating nurse who preps the patient, not the surgeon. Third, the entire team (surgeon, anesthesiologist, circulating nurse, scrub tech) should have done a "time out" just before the incision was made. If the surgeon refuses to participate, the scrub tech does not hand him the scalpel and the circulator initiates the "time out" and the surgeon is reported to the medical review committees. Surely, this well know hospital must have a policy that these procedures are followed and have established mechanisms to assure that this happens. These are basic patient safety procedures.

if the surgeon is late for surgery what preparations are done for the patient while waiting.

Comments from an OR Nurse Leader:

THESE ARE GLOBAL COMMENTS: Not meant to imply what BIDMC does now or did in this particular case. As an OR Nurse my prayers & concerns go out to the patient & family of this case; AND especially to the OR surgical team directly involved in this patient's care. It is my hope that each one of you is getting the support you need after this event.

1. Health care consumers do not have the benefit of understanding how complex with well over 500 touch points, where someone, something is being done to prep a patient for surgery; starting at the surgeons office when they decide to have surgery, doctors office schedules surgery with hospital, doctor calls patient to communicate date of surgery, patient is worked up for surgery, see internist, run tests at internist, or patient may come into hospital to a pre-surgery screening clinic; labs drawn x-rays taken at hospital, specimens sent to lab, specimens analyzed, results sent to all appropriate personnel & hospital, make sure the results get in the correct chart (very trick now as some hospitals are all paper charts, some are a combination of paper & electronic, & some are all electronic, hospital staff interview patient weeks before surgery, anesthesia may want to see patient; additional tests may be ordered based upon new information gathered; results posted in chart & sent to appropriate doctors, anesthesia to re-review patient chart to see if they will clear patient for surgery; if cleared anesthesiologist needs to write clearance note in patients chart; chart assembled and reviewed by pre-surgery screening clinic (PAT) to make sure all data needed for safe patient care is present & no abnormal tests are present; if abnormal tests PAT staff contact surgeon; more tests may be ordered...then follow same routine to get tests done & results in chart, then anesthesia reviews chart again; patient approved for surgery; if a papaer chart it is then transported to the Pre-Op holding area next to the OR so the pre-op nurses can review the chart again the day before surgery. I could go on with the routines for the day of surgery. However the point that I am trying to make is there are many points where information can not be conveyed properly in todays hospitals

2. So the public does not panic; this has been the procedure in hospitals across the country for many years. What is better today is the ability to automate or use computers more to streamline the process and to provide LEGIBLE documents easy to read by the entire team.

3. Throughout the entire sequence of events listed in #1 all healthcare providers from the doctors offices, labs, scheduling, to each hospital patient care unit is verifying the patients name, the surgery they are having & the site/side location.

4. Not one surgical team member (surgeon, anesthesia, nurse, scrub tech, etc) comes to work in the moring desiring to harm a patient. Research has shown it is not the surgical team member who makes the mistake, it is a failure of SYSTEMS. As you can see in #1 there are many different systems operating, with many different people communicating information..... in other words many chances for a breakdown in the system such as a piece of information not being typed into a computer correctly; that can happen.

Am I justifying or trying to make light of this tragic error? No absolutely not, many hospitals are calling this a NEVER EVENT, or some refer to the time out protocol as RED RULES, meaning without exception the policy must be followed to the letter. I agree with the federal and state regulatory stances in some states to deny reimbursement to hospitals for care rendered involving a patient with a wrong site surgery.

It is my opinion that this move will finally provide the teeth needed for the OR leadership to enforce compliance with following the protocol. I have heard from some of my OR nursing colleagues of surgeons who refuse to do the time out stating "this will never happen to me I have been a surgeon for 20+ years..." Such was the case at a Rhode Island hospital last fall. These are the exception, as there are also many more surgeons who are advocates of the protocol & will partner with nursing to help get their colleagues on board.

Even in 2008, with all the advances in technology, and many positive socio-cultural advances in society, the medical model retains its hierarchal structure, and some may go as far to refer to it as patriarchal. WIth that being said some members of the surgical team (Nurses, Surgical techs, Nurse Anesthetists) have been "pressured" by surgeons to not conduct the time out. Unfortunately many OR staff fear retaliation (loss of job, poor treatment in future by the surgeon) if they attempt to stand up to the surgeon). Additionally many hospital administrators when enforcing the protocol are faced with some surgeons threatening to take their cases down the street if they make them). Again let me stress that these surgeons are the EXCEPTION and not the norm. The lay public may not understand this pressure...think back to a time in your doctor's office when you wanted to ask them a question. You may have been frightened to ask. Not quite the same level of pressure, hopefully you get the idea. Additionally the surgical team is expected to move quickly between cases, so the patients don't wait long with out food, & the surgeon has a busy office full of patients waiting to see them.

JCAHO (Joint Commission of Accreditation of Hospitals Organizations) who surveys hospitals across the nation to ensure they are running safe; now says the majority of reasons wrong site surgeries continue to happen is failure of the hospital staff (doctors, nurses, anesthesia, surgical techs) to follow the procedure. 99.99% this not a negligent act by any member of the surgical team, it is a break down in systems; some of which is driven by the medical culture; excessive emphasis on efficiency causing team members to cut corners, highly complex delivery system with multiple hand-offs or communication points, and finally the lack of zero tolerance rules backed ( w/ severe penalties for any member of the team) by senior hospital administration.

Until ZERO TOLERANCE rules are in effect & are adhered to wrong site surgery will continue to happen, even in one of our best hospitals like BIDMC.

Comments from an OR Nurse Leader..... PART 2

So as to not to appear pointing fingers just at Surgeons, my fellow OR nursing leaders must back their front line care givers. However, I am not naive to think that is all that is necessary; clear policies that outline the specific steps must be crafted by OR Directors, who in turn will need to reference denial of reimbursements to their senior administration, to take the next step towards zero tolerance.

Having worked as a circulating nurse, I too have felt the pressure of a surgeon asking me every 1 to 2 minutes "can I bring my patient into the room now" and know how easy it is to give into their nagging. We have always taken pride in the fact that we are the patients advocate while they are asleep during surgery. I also know how second nature it is to ask the patient "when was the last time you had anything to eat or drink" everyone of us just does this every time......the Universal Protocol or Time Out needs to become an every day, every patient habit just like checking if they ate!

Redundancy has been purposely placed throughout the protocol that is done from the time the patient decides to have surgery (by verifying the correct side/site) all the way into the operating room. At multiple points within the hospital before arriving at surgery some of the following point are verified.

In the OR, when the final time out is conducted; the patient is asleep on the OR table, prepped & draped; and the ENTIRE team ACTIVELY participates; including ANESTHESIA; by stating patient name, date of birth, surgical procedure, side (if applicable) and site. the patient's position, and if all supplies are ready AT WHICH time the team visualizes the site marked by the surgeon (marked in the preop area before entering OR).

I like to view the surgical team as an intra-dependent team, meaning that the surgery can not take place if one of the team members are not present. The circulating nurse is the 'conductor" in charge of keeping the harmony of the room, anticipating the need of the surgical team, and advocating for the safe care of the patient. Nursing plays a vital role in the OR and we need to empower the nurse at the bedside to "stop the line" if necessary.

I had surgery and mark , YES correct side and NO incorrect side , on my body in pen. I was light under anesthesia and heard my surgeon yelling how dare I mark the sides in pen and if they couldn't scrub off the pen , he would cancel the surgery. The OR nurse show the doctor the pen came off easily. But he was still angry, so he cut a large incision in me and said she'll now know I cut the correct side. Then I was out. The next day he comforted me about it. He then realized I heard the conversation. Anyway I think he was insulted that I wrote correct and incorrect on my body.

I found lots of interesting information on www.boston.com. The post was professionally written and I feel like the author has extensive knowledge in the subject. www.boston.com keep it that way.