The Massachusetts health blogosphere has lit up with (3 links) discussions of the wrong-site surgery performed at Beth Israel Deaconess Medical Center. In case you missed the story, an experienced surgeon operated on the wrong side of a patient. The error appears to have occurred because the team did not take a “time out” in the moment before the operation to ensure the “right patient, right procedure, right location.” The error was discovered as the patient was recovering. According to hospital CEO Paul Levy’s blog, the hospital’s patient safety department immediately began “investigating, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology” (see Paul’s follow-up post, too)
This must be said first – even if it’s been said many times in the last week – this was a tragic and inexcusable mistake. The patient who was harmed like this may never be the same. It is likely that the clinicians involved are changed as well. An error like this does more than physical and financial damage; it also can destroy trust and is a traumatic emotional event. That is why the Boston area is lucky to have MITSS (Medically Induced Trauma Support Services) to support patients and providers emotionally after medical errors.
Second however, HCFA is glad that BIDMC is doing the right thing in the wake of this serious and preventable surgical error. By disclosing the truth to the patient, investigating the error, working with the patient to ensure his/her health and recovery, and by reporting the error to the public, BIDMC is doing exactly what our Consumer Health Quality Council members – each of whom have themselves been affected by medical errors or other health care quality problems – have been demanding over the last two years.
In the Globe article, DPH’s Paul Dreyer states that DPH received reports of five wrong site surgeries in the first five months of this year alone. With one a month being reported, everyone knows these are far more common than any of us is comfortable with. This incident is just the one that the public have heard about.
For that reason, HCFA believes strongly in the public reporting of and non-payment for serious reportable events, which our Consumer Health Quality Council has been advocating this legislative session. Such a provision was included in Senator Murray’s cost and quality bill that passed the Senate months ago and is pending in the House. The state through its insurers and Blue Cross Blue Shield also recently instituted non-payment policies.
Not included in the cost and quality bill are the two critically important things that BIDMC did before it reported to this error to the public – disclose and apologize. They communicated honestly with the patient first. The surgeon gave a personal apology. HCFA and the Consumer Council have been advocating for mandatory disclosure of adverse events because if something goes wrong with your body you ought to know, and for apology immunity because providers are human after all and earnest communication is at the heart of healing.
Our Consumer Health Quality Council was disappointed not to see disclosure or apology included the in the cost and quality bill, but it will keep advocating for these ideas. They are the right things to do in a tragic situation like this one. This story is creating so much buzz because it is rarer for a hospital to take these steps than it is for them to make this kind of error. HCFA and the Consumer Council hope that other hospitals follow the lead – disclose errors to patients, encourage doctors to apologize, report quality information to the public, and work to ensure that similar errors are prevented.
James Madden
Outgoing Consumer Health Quality Organizer
2009 OF MAY. MY SURG ALMOST REMOVE A LUMP OUT OF THE WRONG ARM. HE SHOULD HAVE DID THE LEFT BUT INSTEAD HE STARTED ON THE RIGHT ARM. HE DID NOT EVEN MENTION IT. I NOTICE A SCRATCH ON THE SKIN OF MY RIGHT ARM.