It took a letter to Gov. Deval Patrick for health officials to recognize the medical errors that harmed Michael Hicks of Quincy, Massachusetts. Hicks’ story recently appeared in the Boston Herald as it became evident that the 40-year-old Quincy man was discharged from Beth Israel Deaconess Hospital last summer without having received proper care. Hicks’ surgery preceded the July 2008 incident at Beth Israel where an experienced surgeon performed on the wrong body part, a serious “never event” – meaning, it should never happen – which shocked many and captured the media’s attention. Hicks’ story now seems to be having a similar effect.
Hicks entered Beth Israel on June 27th and underwent a botched chest reduction and liposuction. Dr. Loren Borud (who has since been fired) performed Hicks surgery while impaired. Though the operating room staff suspected that Borud was in no condition to perform the surgery, no effort was made to report the incident and no administrator was made aware of the situation. Borud nodded off during the surgery and left the operating room before the procedure was complete. A less experienced fellow was left in charge without supervision from Borud despite his repeated requests for an attending physician. This violates certain rules, as fellows are not allowed to be in operating rooms without appropriate supervision. After the surgery, Hicks was never assessed by a physician at Beth Israel before he was discharged from the hospital.
When it became clear to Hicks that something had gone wrong, the Department of Public Health was urged to investigate the incident. While an investigation was made, the case was closed shortly after, clearing Beth Israel of charges of providing poor quality care to Hicks. According to the Herald article, DPH investigators never interviewed Hicks or the fellow left in charge after Borud left the operating room. After Hicks sent a letter to Gov. Deval Patrick, the case was reopened and more evidence emerged stating there had been allegations that Borud had been impaired in another surgery prior to Hicks’. Beth Israel must now present DPH with a corrective action plan, which we hope will include the use of a surgical checklist of care.
HCFA and the Consumer Health Quality Council are supporting a bill filed by Senator Richard Moore (D-Uxbridge) and Representative Denise Provost (D-Somerville) aimed at implementing a checklist to reduce the occurrence of medical errors (.pdf). One of the goals of a checklist is to improve the communication between all hospital personnel in the operating room, allowing everyone to feel more like a team and thus more likely to speak up if someone is concerned about something. It has become clear that the fellow and others in the room with Borud knew he was impaired and did not speak up or do anything about it because, we can assume, of Borud’s level of authority over them. A checklist not only ensures that certain steps are taken but also allows members of the team to feel they can communicate and stop a procedure if something is wrong.
Medical errors happen more than we think. It shouldn’t take Hicks’ story or the occurrence of a startling “never event” for us to consider how to improve the health care we receive in Massachusetts. Medical errors injure approximately 1 million Americans ever year during the course of their hospital stay and up to 100,000 die as a result. Hicks’ story is just one story of many happening in Massachusetts…but it doesn’t have to be this way.
Kuong Ly
