During these couple of weeks following our wrong-side surgery, a number of people
have asked me if we intend to punish the surgeon in charge of the case, as well as other people in the operating room, who did not carry out the expected time-out procedure.
My initial and immediate reaction has always been, "No, these people have been punished enough by the searing experience of the event. They were devastated by their error and distraught to think that they could have participated in an event that unnecessarily hurt a patient. The surgeon immediately reported the error to his Chief and to me and took all appropriate actions to disclose and apologize to the patient, as well as participate openly and honestly in the case review."
This reaction was supported by one of our trustees, who likewise responded, "God has already taken care of the punishment." But another trustee said that it just didn’t feel right that this highly trained physician, "who should have known better," would not be punished. "Wouldn’t someone in another field be disciplined for an equivalent error?" this trustee asked.
This is a healthy debate for us to have, but a comment yesterday made
me realize that I was over-emphasizing the wrong point (i.e., the
doctor’s sense of regret) and not clearly enunciating the full reason
for my conclusion. The head of our faculty practice put it better than
I had: "If our goal is to reduce the likelihood of this kind of error
in the future, the probability of doing that is much greater if these
staff members are not punished than if they are."
I think he is exactly
right, and I believe this is the heart of the logic shared by our
chiefs of service during their review of the case. Punishment in this
situation is more likely to contribute to a culture of people hiding
their errors rather than admitting them. And it is only by having a
culture in which people freely disclose errors that the hospital as a
whole can focus on the human and systemic determinants of those errors.
I believe this conclusion is supported by most of the advanced thinkers
in this field, but I ask them and others of you to comment on that
theory of the case.
But, then we are left with a follow-on question: Under what
circumstances does the need to punish someone trump the other concerns
about institutional learning and a no-blame environment? Beyond the
obvious case in which a doctor or nurse intentionally harms a patient
— where no one would doubt the application of punishment — I am
afraid that the answer is, "It depends."
We had a circumstance a couple of years ago in which a doctor
intentionally left the OR to consult on another patient while his first
patient was in mid-surgery. His logic was that there was a natural
break in the procedure during which a tourniquet had to be released for
a period of time to permit a limb to reprofuse, and that there was no
risk to the patient by his absence. However, he left no attending
physician in the room, only residents — a clear violation of the
rules. No harm whatsoever befell the patient, who in fact was
ultimately very grateful to this surgeon for completing a very
Upon review of this case, our Medical Executive Committee felt that the
violation of an important rule was so clear that the surgeon should be
penalized, and he was suspended for a period of time and the case was
reported to the state licensing board.
A friend today asked me what would distinguish a case like that from
the recent one in which our surgeon failed to conduct a time-out before
beginning the operation. Honestly, it may have been the fact that a
case had recently occurred at another hospital in town, where a surgeon
left the OR and did put a patient more at risk, and where the publicity
concerning that event was widespread. In short, everyone’s sensitivity
had been raised. But I think the MEC response had more to do with their
conclusion that the surgeon knowingly and intentionally left the room
unsupervised, feeling that the rule didn’t really need to apply to him
in that case.
Is that distinguishable from failing to conduct a time-out before a
surgical case? I guess intent should matter. In the more recent case,
the surgeon clearly did not intend to skip the time-out. His mind was
on other things, and he did it inadvertently. While that is, in great
measure, his fault, it also suggests to us hospital leaders that there
is a flaw in the training we provide or the procedures we implement. In
other words, we participated in this error by not having the wisdom to
design a sufficiently fail-safe system that would protect the surgeon
(and of course, the patient) from inadvertently missing the time-out.
Please understand that I am not saying this to absolve the surgeon from
his responsibility. I am saying that to reiterate the point I make
above: We should err on the side of encouraging disclosure and honesty
about errors so we can properly do our job to re-design systems of care
to reduce the chance of error.
While knowing this may appear to contradict what I just said,
there might be cases in the future that are remarkably similar to the
one we just had where we as a management team decide that a punishment
should be meted out. It is not clear to me that we can have exact
rules, in advance, that would draw the distinction. I think this is one
area were we must maintain the right to exercise our discretion
depending on the particular circumstances of the case.
What has been accuring at the facility i am involved in is that the Nurse in the Operating room is being punished and written up. The surgeon takes no punishment and this has lead to many Nurses feeling that disclosing errors could mean loss of their license and for many there livelyhood. It has caused us much pain and suffering espically because the time out is suppose to be initiated by the surgeon. Many times Nurses are very busy and are distracted by many anomolies that occur in a Operating Room. Getting eveyone attention in the room is his priority to the team in the room. The Hospital i am employed at feels the Nurse should be punished, because dismissing a potential Surgeon might mean a loss of revenue for the Hospital. Our Nurses are all afraid to loss jobs and possibly the license we have held for so many years. Never having been part of a wrong site surgery, i do not know the shame of being the Nurse involved.However, I can say that when it did occur even the Nurses not involved felt pain, and knew that it could have happened to anyone of us. The Nurse involved was distaught and has never really gotten over it. The Health department is trying to remove her license and the Surgeon has had no punitive damage. I believe we are all human and errors can accur to anyone but I do not feel the Nurse in the Operating room should be the scap goat when these errors occur.Surgeons need to step up and report their error and make ammends by finding a system that works.
There must be some type of punishment/correction in the system to where the surgeon learns how to prevent such errors and in the process, future medical staff and surgeons learn the importance of practicing the time-out procedures. The surgeon should be required to teach/practice the proper time-out process to future medical staff and surgeons so that they are aware of its critical importance. I can only imagine it would be uncomfortable for the surgeon, who made the error, to be made an example of. However, it would serve as a lesson to help grow and learn from the mistake. Thus making hospitals more proactive and not allowing history to repeat itself.
Sorry but the real problem is that the surgeon has not inculcated into HIS practice that time-outs are an essential element of good surgical care, as important as impeccable sterile technique and knowledge of anatomy. Do you think he would ever forget to scrub prior to a case? Safety elements, including the checklists, have to be seen in the same light. They are not things that the nurses are required to do before the doctor can do his or her thing. In rendering this opinion, I don’t discount the significant role our production model of health care contributes to causing errors. The surgeon may now be your most effective advocate for the time out process. I’d put him to work educating your medical staff and, perhaps more importantly, your house staff.
I thinks doctors should have some limitations and should be scared of some rules. Punishment can be on of them. Other wise some doctors are either lazy or not interested in their careers any more.
One question regarding wrong site surgeries and other similar medical “never events” would be why nobody notices that there doesn’t appear to be anything wrong with the patient at the surgical site. Why does the surgery continue in the absence of a clear clinical indication that the surgery is medically necessary? This is the aspect that I wonder about the most. Do we just cut on auto-pilot?
I agree with you, thanks