Hospital tells of surgery on wrong side

By Stephen Smith
20july 2008--An experienced surgeon at Beth Israel Deaconess Medical Center operated on the wrong side of a patient this week, a serious medical mistake disclosed in an e-mail that hospital administrators sent to staff members yesterday.
State authorities are investigating the errant surgery, which happened Monday during an elective procedure. A hospital administrator declined to provide specifics about the operation but said it did not involve removal of organs and did not cause permanent damage to the middle-aged patient, who was expected to suffer short-term discomfort. A state health regulator described the operation as an orthopedic procedure.
The mistake happened as hospitals, regulators, and insurers are devoting unprecedented attention to combating medical errors. Last month, the state said it would stop reimbursing hospitals for medical costs associated with mistakes.
Figures from the state show that in the first five months of the year, hospitals statewide reported five wrong-sided surgeries. On average, about 15 such errors are reported annually, said Paul Dreyer, director of the state's Bureau of Health Care Safety and Quality.
The error was made at a hospital whose chief executive officer, Paul Levy, has embarked on a personal crusade to reduce medical mistakes, regularly blogging about the issue. Levy has challenged other hospitals to be as forthcoming as his own in publicly disclosing rates of hospital-acquired infections and other preventable events.
A national specialist in the field of patient safety said hospitals are increasingly owning up to mistakes but described Levy's decision to send an e-mail to hundreds of staff members as an unusual act of openness.
When a medical mistake happens, "it's everybody's worst nightmare," said Jim Conway, a senior vice president at the Institute for Healthcare Improvement, a Cambridge think tank that works with hospitals to improve safety. "So what you want to do is disclose it to the [hospital] community, so the community can figure out how they can advance their practice and advance their role so this never happens again."
Dr. Kenneth Sands, senior vice president of healthcare quality at Beth Israel Deaconess, said it had been "at least several years" since such an error had been made at the hospital, an affiliate of Harvard Medical School.
The memo signed by Sands and Levy describes the surgery as "a horrifying story."
According to that document and an interview with Sands, the patient underwent surgery on a hectic day. The memo depicts the surgeon as being "distracted by thoughts of how best to approach the case" in the minutes preceding the operation.
While declining to go into detail, Sands said "there are procedures that happen every day and then there are procedures that are somewhat less common, and this was in that latter category." He said the surgery was designed to repair a problem and did not "involve compromise to any vital organ."
The hospital did not disclose the identity of the patient or surgeon, saying that if too many details were revealed, the patient's confidentiality could be compromised.
Sands said medical workers used a marker to correctly label the side of the patient that should have been operated on, but that, somehow, the surgeon failed to notice the marking.
"I think he began prepping without looking for the mark and, for whatever reason, he believed he was on the correct side," Sands said.
Perhaps most crucially, the team of medical workers in the operating room neglected to conduct what is known as a "time out" before the surgeon placed his scalpel on the patient.
Time outs are routine safety procedures that require the operating team to verbally call out, "Right patient, right procedure, right location."
No single individual was to blame for the event, Sands said, and once the surgery began, nothing in the surgical site itself made it apparent to the surgeon he was operating in error.
The mistake was discovered when the patient was in the surgical recovery area. Later that afternoon, the patient was told about the mistake.
"We waited until the patient was awake enough to get the news, and at that point, the surgeon talked to the patient and gave a full explanation and a full apology," Sands said. The surgery left the patient with post-operative discomfort, but no "life-threatening deficit or permanent organ damage."
A state investigator will visit the hospital next week and depending on the findings, the hospital could face sanctions.
The patient has left Beth Israel Deaconess and has made no decision about whether to have the correct operation - and if so, at which hospital, Sands said