Our wrong-side surgery

Recent news reports about wrong-site surgery at a Rhode Island Hospital generated coverage around the country, including here in Syracuse. Today the Post-Standard reported about a wrong-side surgery that occurred at Community General Hospital in 2004.

How could such a thing happen?

It’s the question we asked ourselves, as you can imagine, in the agonizing minutes, hours, and weeks following that day in 2004 when a surgeon performed an arthroscopy on the wrong knee of a patient here.

I learned about this medical error the morning it happened. Later that day I participated in a root cause analysis intended to identify factors that contributed to the error. Participating in the analysis were the surgeon, the operating room personnel, as well as key administrative and quality department staff.

I promptly apologized to the patient for the medical error. I also apologized to the surgeon because our safety processes did not help prevent the error that day.

This wasn’t a willful act. It was a mistake by human beings who are highly capable and who had the best of intentions. The complexity of modern medicine allows us to do much good for patients, but that very complexity can also introduce risk. Hospitals have established internal processes that are designed to reduce the risk of error, but our process failed us – and failed our patient – one day in 2004.

Our first step that day was the root cause analysis. But there were many more steps in the succeeding days and months, each one intended to help us better understand the error and better prevent a recurrence.

- We promptly reported our error to the State Health Department, as required by law. We continued reporting to the state over many months. We acknowledged our error, and we paid a fine.

- I contacted a hospital administrator who had experience with a wrong-site surgery. She helpfully shared with Community General the lessons from that hospital’s experience, including other sources for us to contact and process improvements they made.

- We requested help from the Joint Commission. Specifically we asked for an on-site review of our processes, starting with patient registration and continuing through the process of surgery.

- We visited a local manufacturer and met with the plant manager and a quality engineer to learn more about how industrial processes can reduce the risk of error.

- We hired an operating room nurse consultant (someone with experience in wrong-site surgery cases), who reviewed and helped us improve our processes.

- We made changes in our Universal Protocol, and they were accepted by the Department of Health.

- We re-trained all staff in the safety procedures required by the Universal Protocol, not only in the Operating Room but throughout the hospital.

- Each member of the Medical Staff individually endorsed the Universal Protocol process and committed to follow it.

- We conducted ongoing reviews of compliance with the Universal Protocol, and we audit procedures throughout the hospital to assure proper processes are followed. This surveillance is ongoing.

- We reported all our actions to the Quality Committee and to the Board of Directors. This reporting continues (as recently as our last meeting of the Quality Committee and the last Board meeting).

Because health care involves human beings, mistakes, regrettably, are possible. That’s why we rely on standardized processes that are followed by each member of the care team in a coordinated fashion in each and every case. This safeguards patients from error. But we know that systems too can fail, and the process of improving systems is ongoing.

We have done many things to address the situation that allowed a wrong-side surgery in 2004. But we have not closed the chapter on it. It remains a fresh lesson for all of us who work together each day in the interests of patient safety.