Beth Israel Deaconess Medical Center released details of a medical error to its entire staff following a recent wrong-site surgery.
The surgical team operated on the wrong side of a patient in an elective procedure after they did not conduct a time out to ensure that they had the right patient, site and procedure, according to Paul Levy, president and chief executive officer of the Boston-based 585-bed hospital. Levy, a transparency advocate, published the message on his blog after it was e-mailed to the approximately 10,000 BIDMC employees.
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, Levy wrote in the message. The surgeon made a full apology to the patient who is now recovering from the nonlife-threatening injury, he said.
Wrong-site surgery appears on the National Quality Forum-endorsed list of adverse, reportable events, or never events that should not occur in hospitals. The World Health Organization recently released a safe-surgery checklist that it says helps doctors prepare for procedures and avoid making serious errors. -- by Jean DerGurahian