A message you hope to never send

First, an email sent out on Thursday morning. My commentary follows.

Dear BIDMC Community,

This week at BIDMC, a patient was harmed when something happened that never should happen: A procedure was performed on the wrong body part. With the support of all our chiefs of service, we are sharing this information with the whole organization because there are lessons here for all of us.

While respecting the confidentiality of both the patient and caregivers, here are the key facts: It was an elective procedure, involving an excellent team of providers. 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. In the midst of all this, 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. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology. The patient is now recovering at home from the injury, which is not life-threatening.

What a horrifying story. What important lessons. We learned that
when teams are busy and distracted, it makes it easier to overlook
something. We learned that key safety steps, like the "time out," need
to occur every single time, since even one failure can be serious. We
learned that serious events rarely relate to the performance of any
single person. We learned that we have vulnerabilities that we were not
even aware of, and that there are surely others out there.

Actually, we re-learned all these things, because none of these
observations are new and all of them apply to the entire work place. We
have already made improvements in our process for side/site marking and
procedural time outs; what can you do to apply these lessons to your

The strength of an organization is measured not by counting the
number of successes, but by its response to failure. We have made an
institutional commitment to eliminating harm, and that requires sharing
information about cases such as this so that we all have a chance to
learn from it. We still have more to learn from this case, and changes
that need to be made, and so will be providing more information in the


Kenneth Sands, MD, MPHSenior Vice President, Health Care Quality

Paul LevyPresident and CEO

Before I start, I want to refer you to an excellent story summarizing the case written by Stephen Smith at the Boston Globe.

So, here are a few things you might want to know. The things that went wrong are summarized above and simply should not have happened. The test for our place is to figure out how to make the right things happen 100 percent of the time. As we work on that, I’ll keep you informed.

While I feel incredibly badly about the event, I feel good about the actions taken by individuals and groups right afterward. Here are a few things that went right. (1) The surgeon immediately notified me and his chief of service when he realized that the error had happened. This permitted our Health Care Quality staff to quickly and efficiently interview everyone who was in the OR, while memories were fresh, so we could piece together all the relevant events. (2) The surgeon and others apologized promptly and openly to the patient and explained the nature of the error. (3) When all of our Chiefs of service met to review the case, they unanimously agreed that the case was serious enough that the e-mail above should be sent to all of the thousands of people working in the hospital.

I could not say with any certainty that all three of these things would have happened even three years ago, when people would have been a lot more protective and skittish about this kind of disclosure. But the focus of our hospital on improving quality and safety and our emphasis on eliminating preventable harm and on transparency of our clinical results has taken hold in a very strong way. This is a cooperative effort of the clinical and administrative and lay leadership — and it takes all three groups to make it happen.

On this particular case, though, one of our Board members put it exactly right: "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."

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. Of course, if the patient would agree to participate, that would lend even more power to the story.

As noted by the Board member, "The video could pepper in the stories of near misses and other incidents to keep the lesson broad. The narration would guide the audience to consider challenges and accomplishments — and work ahead. It could be a 20-minute masterpiece, shown at every orientation, nurses meeting, discussed by chiefs, shared at conferences. Transparency as opportunity, social marketing. It would get people talking, and thinking."

Your thoughts and suggestions?

7 replies »

  1. Not true “transparency” or the individuals responsible would be listed so consumers would have an option to not use them. Way too much emphasis on how bad those involved feel – how about a training video tape instead using the patient and patient’s family?? Again,if this were an airline and the pilot landed on the wrong runway, would the observation simply be “The ‘culture of safety’ has not permeated the front lines.”; or did we accept this as adequate for the lack of quality process that allowed nukes to be flown across the country without autorization/awareness. I am NOT advocating punishment, but accountability and a TRUE Six Sigma health care system with transparency for the consumers as well as the involved workers.

  2. The story does not address it, but I wonder if this surgeon was one of those who has, either actively or passively, resisted the notion of a “time out,” considering this step as an insult to his competence. Many excellent surgeons have this attitude, until it happens to him/her, at which time a new religion is discovered. I recognize the need for transparency (sick of this word) in order to have a chance to know when mistakes are being made–but if this involved an airline pilot who ignored his/her checklist, he/she would likely be fired, if still living.

  3. Very interesting story and fortunately there was no tragic end, nor from what you say no permanent injury to the patient. I am certain the most distressed individual was the surgeon and the immediate operative team…Transparency is good in evaluating mistakes, in an atmosphere of non recrimination. Time out’s are important and so is the pre-op protocols.
    I am not certain we need a “reality show” to demonstrate what the institution has done to avoid this error. Why do the surgeon and OR team , or the patient have to flagellate themselves in a more public manner than they have already done.??

  4. Paul–stuff happens, and your reactions are good. However, was BIDMC using the new checklist put together by Atul Gawande’s team and WHO? I had a relative in surgery last week and I checked the pre-op activities against the checklist. But of course I wasnt allowed into the OR to ask about the rest. I have no idea if the hospital concerned used it.
    Is BIDMC using it? It’s been public for 2 weeks. My guess is no…