How far should you go, and still maintain a climate of admitting medical errors?
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{ 11 comments }
Suspend the surgeon. His patients in pain get to wait for his return. Blame is an anti-scientific remedy. Deming, the review of the multiple factors and their prevention, is the sole sensible remedy.
come on…there has to be some “never” events. intent doesnt matter when you know there are two of what yur operating on and you dont bother to make sure you’ve got the right one. dollars to donuts says this surgeon wasnt in the room when the patient was being draped. that is the take home lesson…be there for the patient when the patient goes into the OR.
mike
I still don’t know why Levy sent e-mails to all BI employees concerning this matter.
What does that prove?
As long as “his patients in pain” are fully informed about the surgeon’s record so they can make their own choices about their care. Sorry, but based on past interactions I’m skeptical that health care bureaucracy would permit the necessary reviews even if the surgeon himself wanted them.
I agree with the poster in the article who said this is one where the malpractice system will dispense the proper “punishment.”
My assumption is that a large judgment will render those determined responsible un-insurable in the future.
I am reminded of accounts of pre-flight checklists in the airline business. The fact that the pilot and crew are harmed along with the passengers upon major goofs does seem to be a potent motivator to adhere to the procedure even in the face of a “busy day.”
I would like to be the patient operated on after the wrong site surgery patient. I am guaranteed perfection that way.
I’m now beginning to understand why several excellent surgeons left the BI-Deaconess to move to Lahey Clinic in Burlington, Ma.
I can’t blame them, one bit.
Anon 5:16,
You forgot to mention that those departures occurred back before 2002, when BIDMC was in deep financial and operational trouble.
But what exactly is your point anyway? How does your conclusion derive from this recent case?
I don’t think BIDMC did much terribly wrong with this incident, unless you consider all the PR hoopla they’ve raised inappropriate.
What I do find inappropriate is Paul’s inadvertent mention of severe punishment for a surgeon who left the room to the residents during part of a case where they were sitting around waiting. This is part of the ridiculous culture arising where residents are presumed totally unable to take care of patients and have autonomy, but when they walk out the door next month they are suddenly attending surgeons who are capable of everything.
Meanwhile, if anything were to go awry during a pause in the case it would almost certainly be with the anesthesia yet there is no outcry if you don’t even have a doctor there at all for that. But if you leave the chief surgery resident in the room for 10 minutes you’d better be sanctioned! He’s far too inexperienced to ever leave a patient alone in a room with him during a break in the case. Until next week when he graduates, that is.
I feel horrible for the patient and all the staff involved in the wrong site surgery case. I have been an RN for 26 years and have served in a number of roles in almost every area of staff nursing and in management and administration. I am currently chief quality officer and moonlight as a staff nurse in critical care at a different hospital.
I feel strongly that punishment will do no good. However, it is difficult to reconcile the fact that every day hospital staff members get punished and terminated for far far lesser “crimes”. Failure to punish gives each of these individuals a reason to question. It seems that being rude to a patient or co-worker is worse than operating on the wrong side – and both events are probably rooted in the same cause – not enough time or failing to take the time.
I don’t know what time and productivity factors may be related to this event, but in my personal investigations of life threatening variances, there is always a significant pressure to meet the productivity standards.
Over the past few years the health care worker shortage in the midwest has grown significantly. As a staff nurse in critical care I am frequently presented with a patient load that is well outside the accepted safe staffing levels. I am told there is not enough nurses, no one to cover etc etc. Yet, I see collegues get punished for taking short cuts, and as a group we get stern lectures and poor evaluations when patients or families complain of rudeness or not taking time to explain. It is hard to reconcile this with not punishing such a big deviation from policy that led to real patient harm. Yet, our manager does not get punished for not scheduling enough nuses – after all there aren’t enough.
How does this all relate – it is hard to have a fully structured and documented system of punishment for one group or types of behavior, but not for another group or behavior and it really seems ludicrous to think that if not following the rules leads to unhappiness you get punished, but if it leads to severe harm or death – no punishment for that?
The theory of no punishment is very very attractive. Just like the theory of communism (from those that have to those who need) seems right. But both fail to take into account human motivation, at least earthly human motivation, and several thousand years of western culture and thought. It always seemed odd to me that we have a legal system that will treat the same behavior and intent in two very different ways depending on the outcome. For example, if two people go to a bar, get equally drunk and drive home. The one who swerves left and kills three people goes to jail, the one who swerves right and runs into the ditch gets a fine. In many cases I have witnessed in hospitals, the worse the outcome the lesser the punishment. That seems even more incongruent.
I think if you are going to adopt a system where you only punish willful violations of policy. It has to be throughout the entire organzation – I doubt that any institution is able and ready to do that.
Paul: The point is that you treat your talent like dirt. You can do that because left wing extremist Boston and Massachusetts have an oversupply of doctors. When disrespect goes up, wages go down, workload goes up, those are reliable economic signs of oversupply.
The Commie Commonwealth should be shunned by doctors. To deter the left wing ideologue scapegoating and maltreatment of the clinician.
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