Another Case of Wrong Site Surgery: Are We Averting Our Eyes From Some of the Root Causes?

By  |  July 9, 2008 |  13 

Yet another case of wrong-side surgery, this one at Boston’s Beth-Israel Deaconess Hospital. Though CEO Paul Levy does a nice job discussing the case on his blog, I’ll focus on two aspects Paul neglects: the role of production pressures in errors, and the tension between “no blame” and accountability.

First, I hope you’ll read Paul’s piece (on his always-interesting blog), which includes a courageous memo he and BI-D’s chief of quality Kenneth Sands sent to the entire community describing the case (within the boundaries created by HIPAA). In laying out the “how could this happen,” they say this:

It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details.

Surprised? Hardly. How many days in my hospital and yours don’t look like that?

The concept of “production pressure” is an important one in safety. In a nutshell, every industry – whether it produces CABGs or widgets – has to deal with the tension between safety and throughput. The issue is not whether they experience this tension – that would be like asking if they operate under the Laws of Gravity. Rather, it is how they balance these twin demands.

When my kids were little, they loved going to the International House of Pancakes (IHOP), particularly the one about 15 minutes from my house and a few minutes from San Francisco International Airport (SFO). I personally find the food at IHOP a bit gross, but being a dutiful dad, we would trudge to the IHOP nearly every weekend.

Unfortunately, on most weekend mornings, the line extended 50 feet into the parking lot. Seeing that, I’d push the kids to move on to a decent place for a civilized breakfast. “No, dad, we wanna stay. And the line really moves fast!”

They were right. No matter how long the line, it seemed like we were seated in a matter of minutes, barely enough time to watch more than a couple of 747s fly overhead on their way to Hawaii. How did they manage this kind of throughput?

Once we sat down in the booth, the answer became clear. We were handed our menus within a few seconds. Less than a minute later, a waitress asked for our order. The food was delivered within 6 or 7 minutes. When I paused to catch my breath, the waitress was there. “Is there anything else I can get you this morning?”, she asked helpfully. Any hesitation… and the check instantly appeared, to be settled at the front register. Another family was seated the nanosecond we rose from our seats.

The point is that a business like IHOP – with its relatively low profit margin per customer – is all about production: everything is designed to get you in and out promptly. But production carries a cost: with haste sometimes come mistakes. I remember many times when our cute little syrup well was filled with four boysenberry syrups, rather than the appropriate assortment (maple, strawberry, blueberry, and boysenberry). But that seemed a small price to pay for speed.

In other words, in the ever-present battle between production and reliably getting it right, production wins at the IHOP.

As I mentioned, the South San Francisco IHOP is on the flight path of San Francisco International Airport. The tension between production and safety is particularly acute at SFO, since its two main runways are 738 feet apart (the picture at left is an actual SFO landing, with a bit of an optical illusion. But not much of one – the runways are really close).

The FAA has inviolable rules about throughput, designed to ensure that safety is defended at all costs. For example, when the fog rolls in and the cloud cover falls to 3000 feet (which happens all the time during the summer), one of the two runways is closed, not only gumming up SFO’s works but those of the entire US air traffic control system. And, whatever the weather, planes cannot land more often than one per minute.

In other words, in the aviation industry, in the battle between production and safety, safety wins. And aviation’s remarkable safety record is the result.

I’ve used this IHOP/SFO metaphor many times in speeches to hospital staff and leaders over the past few years, and usually end it by asking audiences: “In its approach to production and safety, does your hospital look more like the IHOP or SFO?” Although things have gotten a bit better over the last couple of years, the answers still run about 10:1 in favor of the IHOP.

So the fact that is was “a hectic day” is a latent error. I’m not naïve – fixing it involves setting limits on production, which slows down the works. And that costs money! Turns out, so does closing a runway. But in aviation, this is a price people are willing to pay for safety.

Will Paul, or any other bold and visionary CEO, commit to paying that price in his or her organization? Will the docs, who can care for more patients (oh yeah, and make more money) from each case? Probably not. But until we all make different choices, it is important to see the “hectic day” at Beth Israel not as a random Act of God but as a conscious choice that prioritizes production over safety. Every day. Virtually everywhere.

The other issue I found fascinating about the Beth Israel case was the discussion about the lack of safety procedures that allowed this error to occur. Again, quoting from the Levy/Sands letter,

In the midst of all this [frenzy], two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a “time out,” that last-minute check when the whole team confirms “right patient, right procedure, right side.” The procedure went ahead.

I’ve discussed the tension between “no blame” and accountability in a previous posting – I continue to find it one of the most interesting and difficult issues in the patient safety field. It would be good to know the context here. Was everybody (surgeon, anesthesiologist, OR nurses) distracted? Was this was the first time any of them had forgotten to perform the Time Out? If so, this would strike me as a “slip”, an honest mistake deserving no blame and an emphasis on designing a more reliable system.

But what if this was a surgeon who always seemed to “forget” the Time Out? (Believe me, they’re out there, and all of them think wrong-site surgery only happens to those other, more careless, surgeons.) To me, willfully ignoring a sensible safety rule (as I believe the Time Out to be, perhaps embedded the more robust WHO-style checklist, as demonstrated here) is not a “no blame” event, but rather one that screams out for accountability.

At some point, systems are people. In the old days – before the modern patient safety movement – nobody thought much about systems, and the fundamental problem was blaming individuals when bad systems were at fault. That was wrong, and got us nowhere in our quest to keep patients safe.

But this is now a decade later, and we do have some pretty good systems for preventing errors, systems that can always be subverted by recalcitrant providers. In such circumstances, the failure is not that of the system but that of the individual, and I believe they should be handled accordingly. Getting this balance right is really tricky, as many of the dozens of comments in response to the Levy blog, as well as the Boston Globe article on the case, illustrate.

Paul Levy ends his post with an eloquent and passionate bit of feedback from one of his Beth Israel-Deaconess board members:

“Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The ‘culture of safety’ has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change.”

Paul goes on to say:
While we explore lots of ideas, one already in my mind and that of this Board member would be to make a video with the actual people – doctors, nurses, surgical techs – who were in the OR at the time to explain what they saw and felt and what they learned from the experience. While they might be in too much distress to do this right now, they might agree over time, and their doing so would create a powerful message at every orientation, at nurses and departmental meetings, and conferences… Transparency as opportunity, social marketing. It would get people talking, and thinking.

I know the arguments against being punitive, but if this was a surgeon who habitually ignored the regulatory and ethical obligation to perform a Time Out, I would go ahead and produce the video as the board member suggests. The difference is that the surgeon would not only be discussing how badly he feels about the error, but also describing what he did during his one-month suspension from the OR. I’m guessing that this small addition would make the video even more memorable.

At some point, these safety rules will need teeth or they’re not rules, only suggestions. And, in many cases, suggestions won’t prevent devastating medical errors.

This is tough stuff, and I’d welcome your thoughts.

About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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  1. etrain July 9, 2008 at 8:16 pm - Reply

    As the VPMA of a small town hospital, I have a tendency to put facilities like BIDMC on a pedestal and look to them as gleaming examples of excellence. I often warn my medical staff members that their unsafe practice behavior would not be tolerated at “higher institutions” like those in Boston of SF. BIDMC should be a “higher institution” and they should be setting the patient safety standard and leading the patient safety charge. I am incredulous that such a simple, boneheaded mistake could cause a problem at a supposedly prestigious facility such as BIDMC. Skipping the surgical time out? What kind of idiotic and backward maneuver is that? I know my rural, cowboy mentality surgeons may try such a stunt once in a while, but that is why the OR nurse (or any of the OR crew) has supreme authority to stop any procedure immediately if there is even a shadow of a dout regarding patient safety. I have had petite 5′ 2″ nurses physically stand between patients and angry 6″8″ surgeons in order to protect the patient and more importantly, the standard of care.

    In this day and age, I always worried that a wrong side/site surgery could happen to me and my facility, but I never thought it would happen to the “higher institutions” that I admired so much.

  2. watchley July 10, 2008 at 12:42 am - Reply

    It constantly amazes me that these errors still continue. Today CNN reports that 19 babies in a neonatal unit in Corpus Cristi Texas received inappropriate heparin doses. In the miltary when there are safety issues a stand down is implemented and the focus is on dealing with the issues. Maybe hospitals should cancel all elective surgeries and get it right. Then again pigs will fly before that happens.

  3. menoalittle July 10, 2008 at 2:31 am - Reply


    Thank you for reporting and offering your observations on this case of extreme cognitive dysfunction…but there may be a root cause for this one. It is a JC,DOH, and hospital requirement, or protocol if you will, that there be a history and physical performed and its findings be recorded on the chart in order for the patient to get into the OR suite. There is a good reason for this, that being so the captain of the ship knows the ship. In days of yore, the attending surgeon examined the patient and recoreded the findings.

    These requirements do not specify who should perform the H & P, so during the nowadays hectic pace, this ritual becomes perfunctory. It does not matter who does it as long as there is something akin to an H & P on the chart. It is often done by a paraprofessional or housestaff or the family doc…and never the attending surgeon. If the orthopaedic surgeon in this case had used his/her examining skills learned in medical school and internship to actually examine the patient and record the findings, it is likely that the cognition in the OR would have protected the surgeon and the patient…but then again, the surgeon and the hospital are paid for the operation. The perioperative care is covered by the OR fee. You get the picture.

    Best regards,


  4. just a patient July 11, 2008 at 5:38 am - Reply

    I am not sure that I will cogently capture my thoughts on this matter given my seething rage over both its occurrence, the medical community’s collective applause for how exemplary the hospital dealt with this, and the excuses put forth for why this sort of thing happens, but I will try. By the way, this is certainly not directed at Bob for whom I have the highest regard, but the links in his post had me following the story for longer than it probably should have. And I write this as a patient who has had several surgeries, not a medical professional.

    Let me start with the hospital’s reaction. While I no doubt believe that there were people involved who have the highest ethical standards and immediately realized that this was a gross breach of the public trust worthy of public disclosure and self reprobation, as someone who has worked extensively in crisis management, I can assure you that there were an equal number of people, whether they be within the medical community, legal community, or crisis management community (would you care to bet that the hospital either already had crisis management consultants under contract or immediately called them in?), who recognized that containing this was impossible and that the only responsible course of action was making lemonade as quickly as possible out of this lemon. By any standards, this hospital is a massive corporation and I am sure it behaves as one.

    Yes the OR is a hectic place. Yes the surgeon had much on his mind. And yes, checklists serve a critical function. But let’s get real here – operating on the wrong body part is an unforgivable sin, and should be treated as such. We are talking about elite members of society here. Especially at BIDMC, all have excelled at every aspect of their training along the way. From high school through the finest colleges; the toughest science courses, acceptance to medical schools, internships, residencies, fellowships…etc. These are not some middle managers who count on being averagely mediocre in order to fit in and keep their jobs. The bureaucracy of a checklist should NEVER be necessary to tell you to operate on the right part!

    There is a wonderful story about the great physicist Richard Feynman who served on the investigation team after the Challenger disaster. He was sitting on a panel and they were laboriously going over the checklists of what could have caused this accident. The rubbers O-rings were a potential source of investigation, but there were other areas that had to be covered first. While sitting on the panel, Feynman called an aide over and asked for a pitcher of ice water. Without any pomp or circumstance, or ritual or task force, he quietly took a smaller version of the O-ring and placed it in the pitcher. Twenty minutes later, he looked at the chair and said he would like to say something, after remaining quiet for much of the day. All looked to him as he rolled up his sleeve, placed his arm in the pitcher, removed the O-ring and proceeded to slam it down on the table where it broke apart into dozens of fragments. The case was solved right there. I imagine a Nobel prize winning physicist who was literally faced with the task of saving manned space exploration had as much on his mind as a surgeon about to perform elective, non-life threatening surgery. But he knew his field well enough to know what to do, without the need for a bureaucracy to dictate the steps.

    There is a solution to this problem and I am sure all of you will think it quite draconian, but if it doesn’t eliminate 100% of these cases, I imagine it will come statistically close. A lot of things can happen in an OR, some of them known potential complications, some of them quite unpredictable. Whenever there is an adverse consequence in either case, it is appropriate to investigate and bring in any and all state, federal, and medical resources to determine what happened, why it happened, and how to reduce the chance of it happening again. But not here. On any given day, thousands of people lose their jobs for making mistakes that, compared to those that can happen in a medical environment, are truly inconsequential. Bob mentioned the air traffic issues at SFO. How ironic. Did you know that if a pilot shows up to work with alcohol in their system, they don’t just lose their job – they are handed a federal criminal indictment? They can simply be walking through the terminal, on the way to their assigned gate, having put no one in any danger yet. It doesn’t matter whether they are actually impaired or not. There is no test. And after their license is revoked, they face time in a federal penitentiary. And this doctor is getting a one month suspension from the OR!!!! I am incredulous.

    I am not suggesting that this doctor should be jailed; I imagine the civil tort system will take care of him. But operating on the wrong body part should always be a per se violation of every medical standard that has ever existed. Whereas much of medicine may actually be rocket science, this is not. As a patient, I want that doctor’s license permanently revoked. There is simply no excuse. And if every surgeon knows that all those years of grueling preparation and personal sacrifice will be forfeited because of stupidity, carelessness, indifference, boredom, or their simple hubris, than I am pretty confident the incident rate will plummet.

  5. btruax July 12, 2008 at 3:26 am - Reply

    We all understand how time pressures, production pressures, and other distractions are contributory factors in such unfortunate cases where bad patient outcomes (or bad outcomes in other industries) occur. However, the surgical timeout is a “team” function and the lack of appropriate timeouts is usually an indication of a problem with the safety culture. Organizations all have Universal Protocol policies but few actually perform periodic audits to see how often the Universal Protocol is followed correctly. Before people point fingers, they need to look within their own organizations to see how often Universal Protocol is violated. They will probably be surprised at their own vulnerabilities.

    Use of forcing functions, such as not allowing the instrument tray to be opened until the Universal Protocol checklist is completed, is a draconian measure. However, if your “safety culture” is such that your Universal Protocol is only a paper policy, you may need to resort to forcing functions.

  6. Ashok V. Daftary July 13, 2008 at 4:05 pm - Reply

    The Second Victim.

    Dr. Wachter:
    I am an internist practicing in a community not far from San Francisco. I look forward to reading your posts, thank you for your enlightened thoughts on topics that would otherwise never have been discussed. I have also recently been a patient and had a major surgical procedure (at UCSF) and only there realized as I viewed medicine from the “other side” how complex processes are and how easy it is for even the most diligent to be error prone.
    Do not for a moment think that I condone errors. However, as one who has committed errors myself which I yet have grave regrets about I would like to take a different direction to this discussion.
    The surgeon at the Beth Israel Medical Center erred, others in the OR suite have also to share some of the blame .I am sure the OR list detailed the extremity and joint being treated.
    The response of Mr. Levine and the surgeon may not have been perfect but they are commendable. A public acknowledgment of a mistake does take some courage, such admissions allow for corrections in the processes that accommodate failure.
    Forgotten, is the erring physician. Yes he/she did not suffer physical harm, the publicity surrounding the incident and some of the condemnation of others has now created a “second victim” who will live with the psychological consequences of his/her errors long after the unfortunate patient has healed and the tort system satisfied. Error correction is necessary but to make it more effective we have also to treat the victims of their often inadvertent errors. Error correction to be complete must incorporate this facet. I have pasted an opinion piece from the BMJ below.
    It is Sunday today ,I have not been to church, forgive me for hogging so much space but I think that the words Jesus used to rebuke the Pharisees two thousand years ago are just as relevant today especially for those who now tar and feather a physician who has already been punished in the court of public opinion.
    “Let he who is without sin cast the first stone.”

    Medical error: the second victim
    When I was a house officer another resident failed to identify the electrocardiographic signs of the pericardial tamponade that would rush the patient to the operating room late that night. The news spread rapidly, the case tried repeatedly before an incredulous jury of peers, who returned a summary judgment of incompetence. I was dismayed by the lack of sympathy and wondered secretly if I could have made the same mistake-and, like the hapless resident, become the second victim of the error.
    Strangely, there is no place for mistakes in modern medicine. Society has entrusted physicians with the burden of understanding and dealing with illness. Although it is often said that “doctors are only human,” technological wonders, the apparent precision of laboratory tests, and innovations that present tangible images of illness have in fact created an expectation of perfection. Patients, who have an understandable need to consider their doctors infallible, have colluded with doctors to deny the existence of error. Hospitals react to every error as an anomaly, for which the solution is to ferret out and blame an individual, with a promise that “it will never happen again.” Paradoxically, this approach has diverted attention from the kind of systematic improvements that could decrease errors. Many errors are built into existing routines and devices, setting up the unwitting physician and patient for disaster. And, although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims.
    Virtually every practitioner knows the sickening realisation of making a bad mistake. You feel singled out and exposed-seized by the instinct to see if anyone has noticed. You agonise about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger. You may become overly attentive to the patient or family, lamenting the failure to do so earlier and, if you haven’t told them, wondering if they know.1-3
    Sadly, the kind of unconditional sympathy and support that is really needed is rarely forthcoming. While there is a norm of not criticising,4 reassurance from colleagues is often grudging or qualified. One reason may be that learning of the failings of others allows physicians to divest their own past errors among the group, making them feel less exposed.5 It has been suggested that the only way to face the guilt after a serious error is through confession, restitution, and absolution.6 But confession is discouraged, passively by the lack of appropriate forums for discussion, and sometimes actively by risk managers and hospital lawyers. Further, there are no institutional mechanisms to aid the grieving process. Even when mistakes are discussed at morbidity and mortality conferences, it is to examine the medical facts rather than the feelings of the patient or physician.
    In the absence of mechanisms for healing, physicians find dysfunctional ways to protect themselves. They often respond to their own mistakes with anger and projection of blame, and may act defensively or callously and blame or scold the patient or other members of the healthcare team. Distress escalates in the face of a malpractice suit. In the long run some physicians are deeply wounded, lose their nerve, burn out, or seek solace in alcohol or drugs.6 My observation is that this number includes some of our most reflective and sensitive colleagues, perhaps most susceptible to injury from their own mistakes.
    What should we do when a colleague makes a mistake? How would we like others to react to our mistakes? How can we make it feel safe to talk about mistakes? In the case of an individual colleague it is important to encourage a description of what happened, and to begin by accepting this assessment and not minimising the importance of the mistake. Disclosing one’s own experience of mistakes can reduce the colleague’s sense of isolation. It is helpful to ask about and acknowledge the emotional impact of the mistake and ask how the colleague is coping.
    If the patient or family is not aware of the mistake the importance of disclosure should be discussed. The physician has an ethical responsibility to tell the patient about an error, especially if the error has caused harm.7 We should acknowledge the pain of implementing this imperative. However, we can convey the great relief it can be to admit a mistake, and that, confronted by an empathetic and apologetic physician, patients and families can be astonishingly forgiving. Only then is it appropriate to approach the mistake with a problem solving focus, to explore what could have been done differently, and what changes can be made at the individual and institution level to prevent recurrence. In the case of the misread electrocardiograph the educational and emotional experience for the resident-and the team-would have been transformed if a respected senior clinician had led an open discussion of the incident and acknowledged the inevitability of mistakes.
    Nurses, pharmacists, and other members of the healthcare team are also susceptible to error and vulnerable to its fallout. Given the hospital hierarchy, they have less latitude to deal with their mistakes: they often bear silent witness to mistakes and agonise over conflicting loyalties to patient, institution, and team. They too are victims.
    I’ll conclude with an assignment for the practising doctor: think back to your last mistake that harmed a patient. Talk to a colleague about it. Notice your colleague’s reactions, and your own. What helps? What makes it harder? Physicians will always make mistakes. The decisive factor will be how we handle them. Patient safety and physician welfare will be well served if we can be more honest about our mistakes to our patients, our colleagues, and ourselves.
    Albert W Wu associate professor
    School of Hygiene and Public Health and School of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA [email protected]

    1. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA 1991;265:2089-94.
    2. Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med 1992;7:424-31.
    3. Newman MC. The emotional impact of mistakes on family physicians. Arch Fam Med 1996;5:71-5.
    4. Rosenthal MM. The incompetent doctor. Behind closed doors. Buckingham: Open University Press, 1995.
    5. Terry JS, Fricchione GL. Facing limitation and failure. The Pharos 1985;Fall:13-8.
    6. Hilfiker D. Healing the wounds. A physician looks at his work. New York: Penguin, 1985.
    7. Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth – ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 1997;12:770-5.

  7. tholt July 14, 2008 at 3:55 am - Reply

    This case seems so black and white. The necessary time out was not taken and the error occurred. In my experience this type of black and white error is rare. I think 99.9% of patient harm occurs in the grey area of clinical diagnosis and judgement. Daily I consider hundreds of pieces of clinical data and make nearly as many clinical decisions. Some of these are wrong. Usually no harm occurs. Usually they are not as clear cut decisions as wrong patient, wrong site and wrong proceedure. The serious clear cut errors I know of occur when I have placed orders for medications and tests in the wrong patient record. Fortunately others on the team have caught these errors, at least the ones I know about.

    Errors in clinical judgement are much more common in my hospital. Some examples: In recent weeks I recall several patients developing pulmonary edema from excessive IV fluids. One nearly died before being recognized in respiratory distress. Patients are often admitted with respiratory distress. There is diagnostic uncertainty and patients are given treatment for multiple conditions including pneumonia, heart failure and COPD. Occasionally they suffer harm from a treatment they don’t need. Patients with low risk conditions are often admitted to the hospital for monitoring by risk averse ED physicians. These patients occasionally suffer harm (beyond the financial harm) from this. In some cases these harms could be avoided with better clinical judgement.

    I don’t know how to apply most of the lessons from this tragedy at from at BIDMC to these common clinical errors. All health professionals and most patients understand that making a diagnosis and choosing treatment comes with diagnostic uncertainty and potential harm. I believe productivity pressure increases the frequency of judgement errors. I believe that a good physician or nurse is less likely to commit judgement errors. We know that we won’t get far by focusing on individual effort. So how do you take a systems approach to improve clinical decision making. Until we answer that question we are only going to impact the fringes of patient safety. I am cynical about any process that relies on human judgement and attention to detail. Can you imagine health care without humans?

  8. Bob Wachter July 20, 2008 at 7:49 pm - Reply

    For those of you interested in this story, there’s been a lively debate on the issue of punishment on Paul Levy’s blog (see here and here), as well as on the WSJ blog, with lots of comments and several citations of my discussion above regarding the role of accountability in the face of willful violations of safety rules. Very complicated stuff, and the debate is appropriate and healthy.

  9. Sophie July 21, 2008 at 7:31 pm - Reply

    Although I appreciate the issue of production pressure, stopping for one minute to do a Time Out prior to the start of a case, and an average of five cases per room per day (=5 min) is not going to give you enough time to add on another case that day…

  10. jb9054 July 25, 2008 at 6:26 am - Reply

    The aviation analogy is much overblown. Any mechanic or crew member who feels that an aircraft is not airworthy can (and should) ensure that it does not leave the ground until the aircraft is fixed. With medicine, and especially surgery, the “aircraft” is deficient by definition, and will be “flying through turbulence” for at least the duration of the operation. The surgeon, once the captain of the ship, or pilot of the aircraft, has surprisingly little control over the conduct of the “flight.” When I am operating, I have no control over the nursing personnel who are required to be in the room. If the operation lasts more than 30 minutes, it’s unlikely that the team will remain intact through the duration of the procedure, mandating that every counted item by recounted while the operation is proceeding, or halted until this is finished. The circulating nurse, whose role once was to ensure that the physicians have what they need, is now more of a data entry clerk, spending most of the case with her back to the operating team, inputting data into a computer. Some of this is tradition that should be discarded, some is required medicolegally, and much is JCAHO originated. None of it makes surgery safer or more efficient. There is more emphasis on process than outcome- I recently almost started an operation with an H&P on the chart that was of another patient with the same last name and a similar but not identical problem. I was not going to do the wrong operation of this patient under any circumstances, as I was the one who had done the preop evaluation, I knew who the patient was and what he needed done, and I personally checked the consent form and chart before I started. We had done the time out, and the chart had been checked by a RN to make sure that all the documents were there, but not that the documents were the right ones.
    All of this is to say that if everyone is in charge, then no one is in charge. If you want to hold me absolutely responsible for what goes on in that OR, give me the authority I need to make sure that it runs right. I’ll hold the team to the same high standard that I hold myself to- if you start the operation, you stay to the end to minimize the chance that anything will get lost or be overlooked, and you maintain full focus on the patient for the duration of the operation. That’s the way to minimize errors.

  11. just a patient July 26, 2008 at 6:25 am - Reply

    jb9054 – you resond to an airline analogy I did not make. My comments had nothing to do with the airworthiness of the craft. The pilot, the ulitmate in-charge individual, is legally bound to a code of professional conduct that dictates that he not drink within a specified number of hours before flying. Egregiously violating that standard brings harsh consequences. As it should in this case (if you read the WSJ blog that Bob referred to, Mr. Levy ackowledges in one post that the correct body part was marked!!!). For you, as the captain of the OR, to argue that you don’t have the authority, or require some additional authority, to make sure you operate on the right body part is ludicrous. A medical profession that has to ask whether a surgeon in this situation should be given a month long suspension as punishment is troubling.

  12. Rhea September 16, 2008 at 2:10 pm - Reply

    This is a great discussion thread, and the very fact that we’re talking about it is a sign that we’re on the right track to addressing these issues. My background as a general surgeon and as an astronaut with three missions into space along with my current work helping hospitals and physicians improve patient safety, has given me a unique perspective that I hope others may find of value.
    1) Dr. Wachter correctly identifies normalization of deviance as an area ripe for investigation. NASA learned the lesson of the hazards of this common human reaction to a safety measure in which there is little or no perceived value. Anyone interested in normalization of deviance should read about the Challenger disaster. The question is not “Do some of the OR clinicians in our hospital try to skip the timeout (or any other safety measure)?”, the questions are “How often does it occur?” (It does at EVERY healthcare institution), and “What do others on the OR team do when that person tries to circumvent the protocol?” etrain described a 5’2″ nurse standing up to the surgeon. Did she do it because she’s feisty or because the hospital leadership not only empowered her to speak up, they insisted upon it? This speaks to a safety system, and yes, aviation (including NASA) has learned of the necessity for such a system.
    2) This comment set my teeth on edge: “The bureaucracy of the checklist should NEVER be necessary to tell you to operate on the right part.” I’ve had the opportunity to work with some of the best and brightest, both in hospitals and in the Space Shuttle. The implication that a checklist is only for those who aren’t “smart enough” to avoid making a mistake is based upon a delusion that education and intellect are ample safeguards against cognitive error. James Reason, Jerome Groopman, and others have relegated this mindset to wishful thinking. My life, and those of my crew, depended upon every one of us having the discipline to use the checklist. Could I have done the procedure correctly 999 times out of 1000 without the checklist? Absolutely. But a system that fails to account for fatigue, stress, task saturation, distraction, or any of a host of other cognitive issues is one that is rife with latent error. To quote John Nance: “The universal constant is that human infallibility is impossible and those who build a system that depends on an absence of serious human mistakes will fail utterly.”
    3) jb9054 reminisces about the good old days when the surgeon was the “captain of the ship”. I agree that the changing of personnel during a procedure is frustrating, and undermines the continuity of a “shared mental model.” There are three options that I see to remedy the situation: a) Mandate that all OR staff remain until the end of the procedure, thereby significantly increasing the staffing costs and dissatisfaction, or b) Shrug your shoulders and blame “the system”, thereby accepting the status quo, or c) Accept the turnover of OR staff during a procedure and standardize the turnover process to maintain continuity of the shared mental model. Speaking of the captain of the ship, does anyone really think that the captain of a destroyer has the staff remain at their stations until the end of the battle? Battles can last for weeks if one includes all the phases (search, detection, prosecution of threat, etc.). In fact, a destroyer functions largely the same in battle as it does on any other day. Personnel turn over in a standardized fashion at a prescribed time and place. That’s called organizational discipline.
    As to ample authority, every surgeon has all of the authority he or she needs. What most lack is leadership training to understand that leadership is more than “I’ll tell you what to do, and you do it.” What healthcare professional is going to buck the surgeon who says, “Listen guys, I know I’m capable of screwing up here, and I need you to back me up every step of the way so that our patient gets the best possible care. Let’s start by doing a thorough time out and then we can spend a minute discussing this procedure to make sure that we’re all on the same page”?
    Dr. Wachter is on the right track in learning lessons from other industries. There are obvious differences between healthcare and aviation, but the reason that aviation (including space travel) adopted these practices is very simple: the practitioners’ lives depended upon their supplanting their egos to a system that is proven to be better, and safer.

  13. Nancy Vehr August 2, 2010 at 5:00 am - Reply

    I have read these comments and the article and I would like to offer some incite.

    My daughter recently had a wrong ovary removed and the day of surgery the hospital and the doctor took full responsibilty and although a very stressfull situation and a tragedy, it was comforting knowing that they admitted their faults.

    Well, I’ve got news for you, that is as far as it goes. The hospital now wants to claim “no responsibility” in the matter, they are blaming the whole thing on the doctor and the doctors insurance company is playing the prove to us your damages card!.

    It is a nightmare that I hope nobody has to go through. You put your life and trust in the hospital, doctor and all those in the surgery and they take out the wrong organ in your body and now they are acting like the patient is the bad guy.

    It is an eye-opening experience.

    Just pay her for her injuries and let’s get this behind us and heal!

    Why do they want to test you and see if you will file a lawsuit?

    Why do they act like everyone is sue crazy?

    Are surgeries so routine that when they take their time-out they don’t concentrate on the task?

    Do they know how they have hurt a young woman and does she matter?

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