After the 'never' event, a checklist

Today Beth Israel Deaconess Medical Center adopted a new protocol for all surgical procedures, designed to avoid the kind of mistakes that led to a wrong-side surgery earlier this year.

On his blog Running a Hospital, CEO Paul Levy calls it a triumph of transparency because openness made possible the hospital staff's broad engagement in correcting the problem. There was wide agreement that the failure of the operating room to take a "time-out" before surgery began violated procedures and ultimately led to the error.

"If you ever needed a clear example of the power of transparency, here it is," Levy writes about new procedures created by a team of about two dozen people.

"No blades, needles, specula or bronchoscopes can be within reach of the surgeon until the full time-out is completed," Levy writes. "Also, a system of 'secret shoppers' has been set up to quietly audit compliance with these procedures. These are people from a variety of disciplines who normally work in the ORs who have been given this additional job responsibility."