Wednesday, September 17, 2008

Wrong-side surgery

Today’s newspaper carries a story about a wrong-side surgery at St. Joseph’s Hospital Health Center. My thoughts go first to the patient – and then to the caregivers at St. Joe’s.

The story recalls a wrong-side surgery that took place at CGH in 2004, about which I wrote last year. I learned about our medical error the morning it happened, and we conducted a root cause analysis that same day. I promptly apologized to the patient for our medical error, and I apologized to the surgeon because our safety processes did not prevent the error.

Hospitals are complex places where modern medicine allows us to do much good for patients, but modern medicine is accompanied by risk. All hospitals rely upon internal processes to reduce the risk of error, but we didn’t follow our process – we failed our patient and we failed each other – one day in 2004.

Following the root cause analysis, we took many other actions to improve our safety processes. We reached out to another hospital administrator who had experienced a wrong-side surgery; she helped us learn from that experience. We invited the Joint Commission to conduct an on-site review, we visited a local company to learn about industrial safety processes, we hired an operating room consultant to help us improve, and we made changes in our Universal Protocol. We re-trained all staff, and each member of the Medical Staff committed to following the Universal Protocol.

Because health care involves human beings, mistakes, regrettably, are possible – not just in the Operating Room, but anywhere. That’s why standardized processes help fallible individuals safeguard patients .

Today's news story reminds us that the lessons from our own wrong-side surgery must remain fresh for all of us.

This posting appeared in a different form on December 16, 2007.

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