CEO of Beth Israel Deaconess Medical Center alerts all staff to wrong-site surgery

In keeping with his goal of transparency, Paul Levy, CEO of Boston's Beth Israel Deaconess Medical Center (BIDMC) recently disclosed to the BIDMC community that a wrong-site surgery had occurred in his facility.

As reported in the Boston Globe, the BIDMC care team neglected to notice the marking on the patient's body that signified the side and site that needed surgery, and the OR team failed to take a "time out" in which they could have verified correct patient, correct procedure, correct location. 

These oversights were contributing factors leading to the wrong-site surgery.  However, according to Levy, once the error had occurred, the surgeon immediately notified the administration so it could investigate why and how it happened. The surgeon and other hospital staff also immediately disclosed the error to the patient and apologized.  Finally, the administration and Chiefs of Service met and jointly agreed they should alert the entire community to the incident.

In the past, Levy suggests, the staff would have been more protective of itself and reluctant to disclose such errors to a broader audience.  Not only did the institution decide to be transparent with its most important constituents, but also a board member now suggests they create an educational tool about the experience to help foster a culture of patient safety:  "Transparency as opportunity, social marketing.  It would get people talking and thinking."

Detailed feedback about current performance - both good and bad- can be extraordinarily valuable in shaping future performance.  Video is a powerful tool for providing objective data to health care providers about how well they are meeting critical quality and safety objectives in their day-to-day work.  Video can also provide insights into barriers in the clinical environment that limit the ability of providers to perform optimally.  Video opens eyes and facilitates transparency at many levels. 

Perhaps Hospital Video Auditing (HVA) could have been helpful here (see interview with surgeon for perspectives on the use of HVA to improve safety).  Video monitoring, for example, could help identify those factors that stand in the way of complete and effective peri-operative safety steps. 

Understanding more about how errors like this occur is the first step toward reducing vulnerabilities and making the health care environment safer.  In order for this to occur, however, we must first be willing to talk about the events and the factors that contributed to them in an open and objective manner.

Levy and his staff are to be commended for choosing the open road.  Paul Levy's blog, Running a Hospital, is worth a visit.