Beth Israel Deaconess follows up on wrong-site surgery, impaired physician

On his blog Running a Hospital, Beth Israel Deaconess CEO Paul Levy posts a memo sent to employees yesterday by Dr. Kenneth Sands, senior vice president of health care quality. Sands updates the staff on two problems over the summer that were reviewed by the state Department of Public Health: wrong-site surgery and a procedure performed by an allegedly impaired physician.

Failure to take a time-out -- a pause to make sure it's the right patient, right procedure, right site -- has been identified as a contributing factor in the wrong-site surgery, one on a list of "never events" because they are both serious and avoidable. The memo acknowledges this, urges everyone to take responsibility, not just the surgeon, and adds a fail-safe provision: The scrub person will not make the scalpel ready to use until after a time-out is done.

In the case of the surgeon who allegedly operated while impaired, the hospital was cited for record-keeping deficiencies but not for failing to ensure proper care, the memo says. The memo does not give details on what happened, but in July the state temporarily suspended the medical license of a plastic surgeon who allegedly performed two operations while impaired and appeared to fall asleep during a patient's liposuction. He was later fired by the hospital.

"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," Sands writes. "This includes improvements in training for staff on what to do should they encounter such a situation."